Provider Demographics
NPI:1720221187
Name:WGCC, LLC
Entity Type:Organization
Organization Name:WGCC, LLC
Other - Org Name:GRACE POINTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-395-0404
Mailing Address - Street 1:PO BOX 336250
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80633-0605
Mailing Address - Country:US
Mailing Address - Phone:970-304-1919
Mailing Address - Fax:970-395-0606
Practice Address - Street 1:1919 68TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-8060
Practice Address - Country:US
Practice Address - Phone:970-304-1919
Practice Address - Fax:970-395-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO065397Medicare Oscar/Certification