Provider Demographics
NPI:1205209764
Name:FAIRACRES MANOR, INC
Entity Type:Organization
Organization Name:FAIRACRES MANOR, INC
Other - Org Name:FAIRACRES MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KORETKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-974-6278
Mailing Address - Street 1:1700 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-5134
Mailing Address - Country:US
Mailing Address - Phone:970-353-3370
Mailing Address - Fax:970-353-9347
Practice Address - Street 1:1700 18TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5134
Practice Address - Country:US
Practice Address - Phone:970-353-3370
Practice Address - Fax:970-353-9347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO020369314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4139994Medicaid
CO4139994Medicaid