Provider Demographics
NPI:1912942251
Name:SL LIBERTY HEIGHTS LLC
Entity Type:Organization
Organization Name:SL LIBERTY HEIGHTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:A/R COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:KYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-481-5207
Mailing Address - Street 1:12105 GUNSTOCK DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921
Mailing Address - Country:US
Mailing Address - Phone:719-481-5207
Mailing Address - Fax:719-481-5035
Practice Address - Street 1:12205 GUNSTOCK DRIVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3624
Practice Address - Country:US
Practice Address - Phone:719-481-5207
Practice Address - Fax:719-481-5035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0635314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO065305Medicare Oscar/Certification
065305Medicare PIN