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?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04070330Medicaid