Provider Demographics
NPI:1407852981
Name:EBEN EZER LUTHERAN CARE CENTER
Entity Type:Organization
Organization Name:EBEN EZER LUTHERAN CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:970-842-2861
Mailing Address - Street 1:122 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:BRUSH
Mailing Address - State:CO
Mailing Address - Zip Code:80723-1702
Mailing Address - Country:US
Mailing Address - Phone:970-842-2861
Mailing Address - Fax:970-842-3148
Practice Address - Street 1:122 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BRUSH
Practice Address - State:CO
Practice Address - Zip Code:80723-1702
Practice Address - Country:US
Practice Address - Phone:970-842-2861
Practice Address - Fax:970-842-3148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0227314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05653365Medicaid
CO05653365Medicaid