Provider Demographics
NPI:1346733987
Name:SSC BERTHOUD OPERATING COMPANY LLC
Entity Type:Organization
Organization Name:SSC BERTHOUD OPERATING COMPANY LLC
Other - Org Name:BERTHOUD LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-467-6793
Mailing Address - Street 1:5300 W SAM HOUSTON PKWY N
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:855 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BERTHOUD
Practice Address - State:CO
Practice Address - Zip Code:80513-1158
Practice Address - Country:US
Practice Address - Phone:970-532-2683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSC BERTHOUD OPERATING COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000161936Medicaid