Provider Demographics
NPI:1477924249
Name:PUEBLO WEST GARDENS
Entity Type:Organization
Organization Name:PUEBLO WEST GARDENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISS
Authorized Official - Middle Name:
Authorized Official - Last Name:PRADO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:719-406-5288
Mailing Address - Street 1:960 E SAXONY DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1586
Mailing Address - Country:US
Mailing Address - Phone:719-924-8624
Mailing Address - Fax:719-924-8993
Practice Address - Street 1:960 E SAXONY DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-1586
Practice Address - Country:US
Practice Address - Phone:719-924-8624
Practice Address - Fax:719-924-8993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23Z781310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22682554Medicaid