Basic Information
| Provider Information | |||||||||
| NPI: | 1770561755 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PONDEROSA CARE COMMUNITIES A, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH STAR REHABILITATION AND CARE COMMUNITY | ||||||||
| 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: | 3039873088 | ||||||||
| FaxNumber: | 3039870434 | ||||||||
| Practice Location | |||||||||
| Address1: | 3185 W ARKANSAS AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802194004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039221169 | ||||||||
| FaxNumber: | 3039340220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | KORETKE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 3039873088 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0169 | CO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 26554739 | 05 | CO | MEDICAID |