Provider Demographics
NPI:1477927440
Name:TRINIDAD ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:TRINIDAD ASSISTED LIVING, LLC
Other - Org Name:THE LEGACY AT TRINIDAD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:BEARDSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-596-0169
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64061-0023
Mailing Address - Country:US
Mailing Address - Phone:423-596-0169
Mailing Address - Fax:
Practice Address - Street 1:33 LEGACY LN
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-9300
Practice Address - Country:US
Practice Address - Phone:719-846-8662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23Z790310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48738336Medicaid
CO23Z790OtherCOLORADO DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT