Provider Demographics
NPI:1225023575
Name:COLORADO FAYETTE MEDICAL CENTER
Entity Type:Organization
Organization Name:COLORADO FAYETTE MEDICAL CENTER
Other - Org Name:PARKVIEW MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHARIES
Authorized Official - Last Name:CROW
Authorized Official - Suffix:
Authorized Official - Credentials:LNFA # 6484 - TEXAS
Authorized Official - Phone:979-725-8564
Mailing Address - Street 1:206 N SMITH ST
Mailing Address - Street 2:
Mailing Address - City:WEIMAR
Mailing Address - State:TX
Mailing Address - Zip Code:78962-1814
Mailing Address - Country:US
Mailing Address - Phone:979-725-8564
Mailing Address - Fax:979-725-6673
Practice Address - Street 1:206 N SMITH ST
Practice Address - Street 2:
Practice Address - City:WEIMAR
Practice Address - State:TX
Practice Address - Zip Code:78962-1814
Practice Address - Country:US
Practice Address - Phone:979-725-8564
Practice Address - Fax:979-725-6673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108981314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000474702Medicaid
TX675922Medicare ID - Type Unspecified