Provider Demographics
NPI:1114085875
Name:STATE OF COLORADO
Entity Type:Organization
Organization Name:STATE OF COLORADO
Other - Org Name:COLORADO VETERANS COMMUNITY LIVING CENTER HOMELAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-852-5118
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:HOMELAKE
Mailing Address - State:CO
Mailing Address - Zip Code:81135-0097
Mailing Address - Country:US
Mailing Address - Phone:719-852-5118
Mailing Address - Fax:719-852-3881
Practice Address - Street 1:3749 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-9403
Practice Address - Country:US
Practice Address - Phone:719-852-5118
Practice Address - Fax:719-852-3881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2023314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05653274Medicaid