Provider Demographics
NPI:1689907792
Name:RESIDENCE AT SKYWAY PARK
Entity Type:Organization
Organization Name:RESIDENCE AT SKYWAY PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MATRAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-444-5007
Mailing Address - Street 1:886 ARCTURUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-7832
Mailing Address - Country:US
Mailing Address - Phone:719-227-7340
Mailing Address - Fax:719-227-7344
Practice Address - Street 1:886 ARCTURUS DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-7832
Practice Address - Country:US
Practice Address - Phone:719-227-7340
Practice Address - Fax:719-227-7344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23S681310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility