Provider Demographics
NPI:1558612093
Name:PALISADES I MSL LLC
Entity Type:Organization
Organization Name:PALISADES I MSL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:HINES
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-242-1410
Mailing Address - Street 1:4 PARK PLZ STE 500
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5209
Mailing Address - Country:US
Mailing Address - Phone:949-242-1414
Mailing Address - Fax:
Practice Address - Street 1:4547 PALISADES PARK VW
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-8697
Practice Address - Country:US
Practice Address - Phone:719-226-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MBK SENIOR LIVING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23U762310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1407143423Medicaid
UT1568759488Medicaid
UT1578850590Medicaid