Provider Demographics
NPI:1639130727
Name:LA JUNTA LTC INVESTORS
Entity Type:Organization
Organization Name:LA JUNTA LTC INVESTORS
Other - Org Name:EVERGREEN GARDENS AT LA JUNTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:KANEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-589-2063
Mailing Address - Street 1:2415 MULLINS AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-4274
Mailing Address - Country:US
Mailing Address - Phone:719-589-2063
Mailing Address - Fax:719-589-8891
Practice Address - Street 1:909 W 10TH ST
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2168
Practice Address - Country:US
Practice Address - Phone:719-384-9333
Practice Address - Fax:719-384-9393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAL-0239310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03805565Medicaid