Provider Demographics
NPI:1346697471
Name:12TH STREET OPERATIONS, LLC
Entity Type:Organization
Organization Name:12TH STREET OPERATIONS, LLC
Other - Org Name:PIONEER HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF A/R-COLORADO
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-876-9252
Mailing Address - Street 1:26522 LA ALAMEDA STE 300
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8302
Mailing Address - Country:US
Mailing Address - Phone:949-449-2500
Mailing Address - Fax:
Practice Address - Street 1:900 S 12TH ST
Practice Address - Street 2:
Practice Address - City:ROCKY FORD
Practice Address - State:CO
Practice Address - Zip Code:81067-2128
Practice Address - Country:US
Practice Address - Phone:619-876-9252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33155071Medicaid
CO9000142633Medicaid