Basic Information
| Provider Information | |||||||||
| NPI: | 1124029053 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BSMC LIMITED LIABILITY COMPANY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BROOKSIDE INN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1297 S PERRY ST | ||||||||
| Address2: | |||||||||
| City: | CASTLE ROCK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801041977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036882500 | ||||||||
| FaxNumber: | 3036882600 | ||||||||
| Practice Location | |||||||||
| Address1: | 1297 S PERRY ST | ||||||||
| Address2: | |||||||||
| City: | CASTLE ROCK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801041977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036882500 | ||||||||
| FaxNumber: | 3036882600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 03/11/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHUMANN | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3036882500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0380 | CO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 05652813 | 05 | CO | MEDICAID |