Basic Information
| Provider Information | |||||||||
| NPI: | 1831149962 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 656 DILLON WAY OPERATIONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASPEN CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | REIMBURSEMENT | ||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054684742 | ||||||||
| FaxNumber: | 5054688742 | ||||||||
| Practice Location | |||||||||
| Address1: | 656 DILLON WAY | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800116803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033440636 | ||||||||
| FaxNumber: | 3033440639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 12/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | DIVITTORIO | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO, TREASURER, ASST SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6104446350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNBRIDGE HEALTHCARE LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | N | Respite Care Facility | Respite Care | 314000000X | 0389 | CO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 05652953 | 05 | CO | MEDICAID | 7100495 | 01 | CO | EVERCARE | OTHER | 522089013 | 01 | CO | COLORADO ACCESS | OTHER |