Provider Demographics
NPI:1265832224
Name:329 EXEMPLA CIRCLE OPERATIONS LLC
Entity Type:Organization
Organization Name:329 EXEMPLA CIRCLE OPERATIONS LLC
Other - Org Name:POWERBACK REBAHILITATION LAFAYETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:329 EXEMPLA CIR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3463
Mailing Address - Country:US
Mailing Address - Phone:555-555-5555
Mailing Address - Fax:
Practice Address - Street 1:329 EXEMPLA CIR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3463
Practice Address - Country:US
Practice Address - Phone:555-555-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS OPERATIONS VI LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-27
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00000310400000X
CO0000314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO065414Medicare Oscar/Certification