Provider Demographics
NPI:1942391875
Name:EAGLE RIDGE OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:EAGLE RIDGE OPERATING COMPANY, LLC
Other - Org Name:EAGLE RIDGE AT GRAND VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KORETKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-974-6278
Mailing Address - Street 1:12136 W. BAYAUD AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228
Mailing Address - Country:US
Mailing Address - Phone:720-974-6278
Mailing Address - Fax:303-987-0434
Practice Address - Street 1:2425 TELLER AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-5141
Practice Address - Country:US
Practice Address - Phone:970-243-3381
Practice Address - Fax:970-243-3416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO021116314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO417-081058Medicaid
CO1300-86863Medicaid
CO1300-86863Medicaid