Provider Demographics
NPI:1669055935
Name:BETHESDA GARDENS BROADMOOR COURT LLC
Entity type:Organization
Organization Name:BETHESDA GARDENS BROADMOOR COURT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-481-0100
Mailing Address - Street 1:15475 GLENEAGLE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-2596
Mailing Address - Country:US
Mailing Address - Phone:719-481-0100
Mailing Address - Fax:719-488-6080
Practice Address - Street 1:2045 ROANOKE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3451
Practice Address - Country:US
Practice Address - Phone:719-471-2286
Practice Address - Fax:719-634-0491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility