Provider Demographics
NPI:1336206010
Name:PINE RIDGE EXTENDED CARE CENTER, LLC
Entity Type:Organization
Organization Name:PINE RIDGE EXTENDED CARE CENTER, LLC
Other - Org Name:PINE RIDGE EXTENDED CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
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:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0105385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04183539Medicaid