Basic Information
| Provider Information | |||||||||
| NPI: | 1316989163 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 8451 PEARL STREET OPERATING COMPANY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | VISTA VIEW CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4550 LENA DR | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175915709 | ||||||||
| FaxNumber: | 7175915710 | ||||||||
| Practice Location | |||||||||
| Address1: | 8451 PEARL ST | ||||||||
| Address2: | |||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802294804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032883000 | ||||||||
| FaxNumber: | 3032861253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 11/25/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLINGER | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7175915700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 02R315 | CO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 119348100 | 05 | WY | MEDICAID | 58404015 | 05 | NM | MEDICAID | 58053565 | 05 | CO | MEDICAID | 119348101 | 05 | WY | MEDICAID |