Provider Demographics
NPI:1326620261
Name:STATE OF COLORADO
Entity Type:Organization
Organization Name:STATE OF COLORADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-852-5118
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:HOMELAKE
Mailing Address - State:CO
Mailing Address - Zip Code:81135-0097
Mailing Address - Country:US
Mailing Address - Phone:719-852-8211
Mailing Address - Fax:719-852-3881
Practice Address - Street 1:3749 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-9403
Practice Address - Country:US
Practice Address - Phone:719-852-8211
Practice Address - Fax:719-852-3881
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF COLORADO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000179367Medicaid