Basic Information
| Provider Information | |||||||||
| NPI: | 1508198417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LSREF GOLDEN OPS 14 (WY) LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ASPEN WIND ASSISTED LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3015 16TH ST SW | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587016906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018377103 | ||||||||
| FaxNumber: | 7018387785 | ||||||||
| Practice Location | |||||||||
| Address1: | 4010 N COLLEGE DR | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820011960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077789511 | ||||||||
| FaxNumber: | 3077720977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2010 | ||||||||
| LastUpdateDate: | 02/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | WENTZ | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE V. PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 7018377103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 10113 | WY | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.