Basic Information
| Provider Information | |||||||||
| NPI: | 1699772533 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SSC COLONIAL COLUMNS CS OPERATING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 E FILLMORE ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194731105 | ||||||||
| FaxNumber: | 7194730495 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 E FILLMORE ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194731105 | ||||||||
| FaxNumber: | 7194730495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHINN | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | STEPHEN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7194731105 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LNHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0427 | CO | X | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 311500000X | 0427 | CO | X | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |
ID Information
| ID | Type | State | Issuer | Description | 05654793 | 05 | CO | MEDICAID |