Provider Demographics
NPI:1568864981
Name:ST PETRO LLC
Entity Type:Organization
Organization Name:ST PETRO LLC
Other - Org Name:ST PETRO LAUREL HAUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-941-9460
Mailing Address - Street 1:7032 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80122
Mailing Address - Country:US
Mailing Address - Phone:303-770-0600
Mailing Address - Fax:303-770-0600
Practice Address - Street 1:7032 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80122
Practice Address - Country:US
Practice Address - Phone:303-770-0600
Practice Address - Fax:303-770-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23I963310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility