Provider Demographics
NPI:1891882957
Name:SOUTH PUEBLO MEDICAL INVESTORS, LLC
Entity Type:Organization
Organization Name:SOUTH PUEBLO MEDICAL INVESTORS, LLC
Other - Org Name:LIFE CARE CENTER OF PUEBLO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-473-5867
Mailing Address - Street 1:3001 KEITH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3713
Mailing Address - Country:US
Mailing Address - Phone:423-473-5751
Mailing Address - Fax:423-339-8342
Practice Address - Street 1:2118 CHATALET LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-4625
Practice Address - Country:US
Practice Address - Phone:719-564-2000
Practice Address - Fax:719-564-7741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0600314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05650742Medicaid
CO05650742Medicaid