Basic Information
| Provider Information | |||||||||
| NPI: | 1023655339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SNH CO TENANT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 WASHINGTON ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024581634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177968350 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 W VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194758686 | ||||||||
| FaxNumber: | 7194751223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2019 | ||||||||
| LastUpdateDate: | 05/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | MINTZER | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6177968350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SNH CO TENANT LLC | ||||||||
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| NPICertificationDate: | 05/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | Y | Respite Care Facility | Respite Care |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | CO | MEDICAID |