Basic Information
| Provider Information | |||||||||
| NPI: | 1588222863 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 1111 BONFORTE OPCO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 855 HUNTER DR. | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81001 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 855 HUNTER DR. | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195455911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2019 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| AuthorizedOfficialLastName: | KIKLIS | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3039529216 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 1111 BONFORTE OPCO LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | N | Respite Care Facility | Respite Care | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.