Provider Demographics
NPI:1700864782
Name:PONDEROSA CARE COMMUNITIES C, LLC
Entity Type:Organization
Organization Name:PONDEROSA CARE COMMUNITIES C, LLC
Other - Org Name:SIERRA REHABILITATION AND CARE COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KORETKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-987-3088
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:303-987-3088
Mailing Address - Fax:303-987-0434
Practice Address - Street 1:1432 DEPEW ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-2237
Practice Address - Country:US
Practice Address - Phone:303-238-1375
Practice Address - Fax:303-238-0852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0098314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16876334Medicaid
CO065272Medicare ID - Type Unspecified
CO16876334Medicaid