Provider Demographics
NPI:1245237494
Name:PINE RIDGE EXTEND CARE CENTER, LLC
Entity type:Organization
Organization Name:PINE RIDGE EXTEND CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:970-731-4330
Mailing Address - Street 1:119 BASTILLE DR
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9388
Mailing Address - Country:US
Mailing Address - Phone:970-731-4330
Mailing Address - Fax:970-731-4046
Practice Address - Street 1:119 BASTILLE DR
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9388
Practice Address - Country:US
Practice Address - Phone:970-731-4330
Practice Address - Fax:970-731-4046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0105314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05652839Medicaid
CO05652839Medicaid