Basic Information
Provider Information | |||||||||
NPI: | 1669807731 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | 1111 BONFORTE OPCO, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VILLA PUEBLO ASSISTED LIVING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2668 NORTHPARK DR | ||||||||
Address2: | SUITE 220 | ||||||||
City: | LAFAYETTE | ||||||||
State: | CO | ||||||||
PostalCode: | 800263199 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3039529216 | ||||||||
FaxNumber: | 3036755659 | ||||||||
Practice Location | |||||||||
Address1: | 855 HUNTER DR | ||||||||
Address2: |   | ||||||||
City: | PUEBLO | ||||||||
State: | CO | ||||||||
PostalCode: | 810011867 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195455911 | ||||||||
FaxNumber: | 7192533709 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2013 | ||||||||
LastUpdateDate: | 09/26/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KIKLIS | ||||||||
AuthorizedOfficialFirstName: | DEAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3039529216 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X |   |   | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.