Provider Demographics
NPI:1326488982
Name:PRAIRIE PINES
Entity Type:Organization
Organization Name:PRAIRIE PINES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-438-2141
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:101 E LOWELL AVE
Mailing Address - City:EADS
Mailing Address - State:CO
Mailing Address - Zip Code:81036-0787
Mailing Address - Country:US
Mailing Address - Phone:719-438-2141
Mailing Address - Fax:719-438-2140
Practice Address - Street 1:101 E LOWELL AVE
Practice Address - Street 2:
Practice Address - City:EADS
Practice Address - State:CO
Practice Address - Zip Code:81036
Practice Address - Country:US
Practice Address - Phone:719-438-2141
Practice Address - Fax:719-438-2140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO09781285310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09781285Medicaid