Provider Demographics
NPI:1396830709
Name:BURLINGTON NURSING HOME LLC
Entity Type:Organization
Organization Name:BURLINGTON NURSING HOME LLC
Other - Org Name:GRACE MANOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:BEARDSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-336-6744
Mailing Address - Street 1:465 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80807-1932
Mailing Address - Country:US
Mailing Address - Phone:719-346-7512
Mailing Address - Fax:719-346-9373
Practice Address - Street 1:465 5TH STREET
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80807-1932
Practice Address - Country:US
Practice Address - Phone:719-346-7512
Practice Address - Fax:719-346-9373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0066314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57475041Medicaid
CO065284Medicare ID - Type UnspecifiedPROVIDER NUMBER