Provider Demographics
NPI:1689665119
Name:BUCKEYE M, LLC
Entity Type:Organization
Organization Name:BUCKEYE M, LLC
Other - Org Name:MESA VISTA OF BOULDER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-238-3838
Mailing Address - Street 1:12136 W BAYAUD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2115
Mailing Address - Country:US
Mailing Address - Phone:303-238-3838
Mailing Address - Fax:303-987-0434
Practice Address - Street 1:2121 MESA DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3621
Practice Address - Country:US
Practice Address - Phone:303-442-4037
Practice Address - Fax:303-442-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0638314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05656400Medicaid
065052Medicare Oscar/Certification
CO0351180001Medicare NSC