Provider Demographics
NPI: | 1477175172 |
---|---|
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: | CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LESLIE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MASON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
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: | |
Practice Address - Street 1: | 1910 EDISON ST |
Practice Address - Street 2: | |
Practice Address - City: | BRUSH |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80723-1743 |
Practice Address - Country: | US |
Practice Address - Phone: | 970-842-2861 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | EBEN EZER LUTHERAN CARE CENTER |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2020-05-15 |
Last Update Date: | 2020-05-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CO | 04070330 | Medicaid |