Provider Demographics
NPI:1669470910
Name:STATE OF COLORADO
Entity Type:Organization
Organization Name:STATE OF COLORADO
Other - Org Name:BRUCE MCCANDLESS COLORADO STATE VETERANS NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, NHA
Authorized Official - Phone:719-784-6331
Mailing Address - Street 1:903 MOORE DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:CO
Mailing Address - Zip Code:81226-9509
Mailing Address - Country:US
Mailing Address - Phone:719-784-6331
Mailing Address - Fax:719-784-5335
Practice Address - Street 1:903 MOORE DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:CO
Practice Address - Zip Code:81226-9509
Practice Address - Country:US
Practice Address - Phone:719-784-6331
Practice Address - Fax:719-784-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0566314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41833015Medicaid
CO056-54223Medicaid