Provider Demographics
NPI:1538331251
Name:COLORADO ASSISTED LIVING AT PTARMIGAN RUN LLC
Entity Type:Organization
Organization Name:COLORADO ASSISTED LIVING AT PTARMIGAN RUN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCREYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-227-9264
Mailing Address - Street 1:629 PTARMIGAN RUN
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:629 PTARMIGAN RUN
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538
Practice Address - Country:US
Practice Address - Phone:970-593-0102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23V639310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO69058059Medicaid