Provider Demographics
NPI:1457673709
Name:GARDEN OF THE GODS SENIOR LIVING LLC
Entity Type:Organization
Organization Name:GARDEN OF THE GODS SENIOR LIVING LLC
Other - Org Name:GARDEN OF THE GODS CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NHA DIRECTOR OF COLORADO OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAFONT
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:303-688-3174
Mailing Address - Street 1:104 LOIS LANE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904
Mailing Address - Country:US
Mailing Address - Phone:719-635-2569
Mailing Address - Fax:719-635-2530
Practice Address - Street 1:104 LOIS LANE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904
Practice Address - Country:US
Practice Address - Phone:719-635-2569
Practice Address - Fax:719-635-2530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
CO020533314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34620885Medicaid
CO34620885Medicaid