Provider Demographics
NPI:1578774592
Name:MESA VISTA ASSISTED LIVING RESIDENCE
Entity Type:Organization
Organization Name:MESA VISTA ASSISTED LIVING RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-595-4464
Mailing Address - Street 1:1510 17TH ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-1202
Mailing Address - Country:US
Mailing Address - Phone:303-595-4464
Mailing Address - Fax:303-595-9225
Practice Address - Street 1:0072 E. SIPPRELLE DR.
Practice Address - Street 2:
Practice Address - City:PARACHUTE
Practice Address - State:CO
Practice Address - Zip Code:81635
Practice Address - Country:US
Practice Address - Phone:970-285-1844
Practice Address - Fax:970-285-6351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAL-0075310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO29224250Medicaid