Basic Information
| Provider Information | |||||||||
| NPI: | 1366450090 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLORADO MEDICAL INVESTORS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CANON LODGE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 KEITH ST NW | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373123713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234735751 | ||||||||
| FaxNumber: | 4233398342 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 HARDING AVE | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812122147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192754106 | ||||||||
| FaxNumber: | 7192752895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CROSS | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4234735867 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | N | Respite Care Facility | Respite Care | 314000000X | 0418 | CO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 05652631 | 05 | CO | MEDICAID |