Basic Information
| Provider Information | |||||||||
| NPI: | 1689665119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUCKEYE M, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MESA VISTA OF BOULDER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12136 W BAYAUD AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802282115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032383838 | ||||||||
| FaxNumber: | 3039870434 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 MESA DR | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034424037 | ||||||||
| FaxNumber: | 3034422348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 04/25/2016 | ||||||||
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| AuthorizedOfficialLastName: | MOSKOWITZ | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3032383838 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0638 | CO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 05656400 | 05 | CO | MEDICAID |