Basic Information
Provider Information | |||||||||
NPI: | 1215910674 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PARK FOREST CARE CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7045 STUART ST | ||||||||
Address2: |   | ||||||||
City: | WESTMINSTER | ||||||||
State: | CO | ||||||||
PostalCode: | 800305820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034277045 | ||||||||
FaxNumber: | 3034270023 | ||||||||
Practice Location | |||||||||
Address1: | 7045 STUART ST | ||||||||
Address2: |   | ||||||||
City: | WESTMINSTER | ||||||||
State: | CO | ||||||||
PostalCode: | 800305820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034277045 | ||||||||
FaxNumber: | 3034270023 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DE LA GARZA | ||||||||
AuthorizedOfficialFirstName: | BEVERLY | ||||||||
AuthorizedOfficialMiddleName: | JEAN | ||||||||
AuthorizedOfficialTitleorPosition: | NURSING HOME ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3034277045 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LICENSED 2116 | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310500000X |   |   | Y |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mental Illness |   |
ID Information
ID | Type | State | Issuer | Description | 05651757 | 05 | CO |   | MEDICAID |