Basic Information
Provider Information | |||||||||
NPI: | 1912679168 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHGLENN OPERATIONS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25115 SW PARKWAY AVE STE B | ||||||||
Address2: |   | ||||||||
City: | WILSONVILLE | ||||||||
State: | OR | ||||||||
PostalCode: | 970708891 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037832489 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 401 MALLEY DR | ||||||||
Address2: |   | ||||||||
City: | NORTHGLENN | ||||||||
State: | CO | ||||||||
PostalCode: | 802332024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034524700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2021 | ||||||||
LastUpdateDate: | 10/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ODERMOTT | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5037832489 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 01279700 | 05 | CO |   | MEDICAID |