Provider Demographics
NPI:1912578279
Name:12080 BELLAIRE WAY OPERATIONS LLC
Entity Type:Organization
Organization Name:12080 BELLAIRE WAY OPERATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
Mailing Address - Street 1:12080 BELLAIRE WAY
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80241-3600
Mailing Address - Country:US
Mailing Address - Phone:303-450-2700
Mailing Address - Fax:303-450-2701
Practice Address - Street 1:12080 BELLAIRE WAY
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80241-3600
Practice Address - Country:US
Practice Address - Phone:303-450-2700
Practice Address - Fax:303-450-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care