Provider Demographics
NPI:1225512619
Name:THE CITADEL ALZHEIMERS AND DEMENTIA ASSISTED LIVING
Entity Type:Organization
Organization Name:THE CITADEL ALZHEIMERS AND DEMENTIA ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-621-1118
Mailing Address - Street 1:431 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:431 QUINCY ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2027
Practice Address - Country:US
Practice Address - Phone:719-621-1118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========Medicaid