Provider Demographics
NPI:1912299785
Name:HAVEN OF CARE ASSISTED LIVING AT TOLLGATE CROSSING
Entity Type:Organization
Organization Name:HAVEN OF CARE ASSISTED LIVING AT TOLLGATE CROSSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MEGAWATI
Authorized Official - Middle Name:
Authorized Official - Last Name:WIRANTONO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-947-7392
Mailing Address - Street 1:PO BOX 461284
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80046-1284
Mailing Address - Country:US
Mailing Address - Phone:303-690-5534
Mailing Address - Fax:303-400-5159
Practice Address - Street 1:5010 S DUQUESNE ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-5866
Practice Address - Country:US
Practice Address - Phone:303-947-7392
Practice Address - Fax:303-400-5159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23D456310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility