Provider Demographics
NPI:1790189785
Name:RESIDENCE AT VILLAGE GREEN, LLC
Entity Type:Organization
Organization Name:RESIDENCE AT VILLAGE GREEN, LLC
Other - Org Name:RESIDENCE AT VILLAGE GREEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATRAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:305-444-5007
Mailing Address - Street 1:3455 N. CAREFREE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-2807
Mailing Address - Country:US
Mailing Address - Phone:719-999-5744
Mailing Address - Fax:719-999-5721
Practice Address - Street 1:3455 N. CAREFREE CIRCLE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-2809
Practice Address - Country:US
Practice Address - Phone:719-999-5744
Practice Address - Fax:719-999-5721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility