Provider Demographics
NPI:1720553357
Name:PEACHTREE ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:PEACHTREE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ORIBELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-434-7062
Mailing Address - Street 1:3450 F RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:CO
Mailing Address - Zip Code:81520-8433
Mailing Address - Country:US
Mailing Address - Phone:970-434-7062
Mailing Address - Fax:970-434-0485
Practice Address - Street 1:3450 F RD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:CO
Practice Address - Zip Code:81520-8433
Practice Address - Country:US
Practice Address - Phone:970-434-7062
Practice Address - Fax:970-434-0485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000143187Medicaid
CO9000143186Medicaid