Basic Information
Provider Information | |||||||||
NPI: | 1154300853 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAIRACRES MANOR, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAIRACRES MANOR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12136 W BAYAUD AVENUE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LAKEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 802282115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039873088 | ||||||||
FaxNumber: | 3039870434 | ||||||||
Practice Location | |||||||||
Address1: | 1700 18TH AVE | ||||||||
Address2: |   | ||||||||
City: | GREELEY | ||||||||
State: | CO | ||||||||
PostalCode: | 806315134 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9703533370 | ||||||||
FaxNumber: | 9703539347 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2006 | ||||||||
LastUpdateDate: | 02/05/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KORETKE | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
AuthorizedOfficialTelephone: | 7209746278 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0576 | CO | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 05653423 | 05 | CO |   | MEDICAID |