Basic Information
| Provider Information | |||||||||
| NPI: | 1538666359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSC FORT COLLINS LEMAY AVENUE OPERATING COMPANY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FORT COLLINS HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 W SAM HOUSTON PKWY N STE 100 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770415162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324676000 | ||||||||
| FaxNumber: | 8324678500 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 S LEMAY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805243914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704827925 | ||||||||
| FaxNumber: | 9704931686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2018 | ||||||||
| LastUpdateDate: | 04/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | PITTS | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 8324676793 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSC FORT COLLINS LEMAY AVENUE OPERATING COMPANY LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | 1291 | CO | Y | Respite Care Facility | Respite Care |
ID Information
| ID | Type | State | Issuer | Description | 9000159189 | 05 | CO | MEDICAID |