Provider Demographics
NPI:1669845129
Name:HOLLY NURSING CARE CENTER, INC
Entity Type:Organization
Organization Name:HOLLY NURSING CARE CENTER, INC
Other - Org Name:HOLLY NURSING CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KORETKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-974-6278
Mailing Address - Street 1:PO BOX 636
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:CO
Mailing Address - Zip Code:81047-0636
Mailing Address - Country:US
Mailing Address - Phone:719-537-6555
Mailing Address - Fax:719-537-6366
Practice Address - Street 1:320 N 8TH ST
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:CO
Practice Address - Zip Code:81047
Practice Address - Country:US
Practice Address - Phone:719-537-6555
Practice Address - Fax:719-537-6366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO020237314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05655147Medicaid
CO4138426Medicaid
CO05655147Medicaid