Provider Demographics
NPI:1588222863
Name:1111 BONFORTE OPCO LLC
Entity Type:Organization
Organization Name:1111 BONFORTE OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIKLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-952-9216
Mailing Address - Street 1:855 HUNTER DR.
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:855 HUNTER DR.
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001
Practice Address - Country:US
Practice Address - Phone:719-545-5911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1111 BONFORTE OPCO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No385H00000XRespite Care FacilityRespite Care