Basic Information
| Provider Information | |||||||||
| NPI: | 1801016688 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNNY VISTA LIVING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2445 E CACHE LA POUDRE ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809094812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194718700 | ||||||||
| FaxNumber: | 7194714352 | ||||||||
| Practice Location | |||||||||
| Address1: | 2445 E CACHE LA POUDRE ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809094812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194718700 | ||||||||
| FaxNumber: | 7194714352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | DENBRABER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7209743900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0094 | CO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 05654025 | 05 | CO | MEDICAID |