Basic Information
Provider Information | |||||||||
NPI: | 1922054956 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FIVE STAR QUALITY CARE-COLORADO LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MANTEY HEIGHTS REHABILITATION & CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2825 PATTERSON RD | ||||||||
Address2: |   | ||||||||
City: | GRAND JUNCTION | ||||||||
State: | CO | ||||||||
PostalCode: | 815066065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702427356 | ||||||||
FaxNumber: | 9702459196 | ||||||||
Practice Location | |||||||||
Address1: | 2825 PATTERSON RD | ||||||||
Address2: |   | ||||||||
City: | GRAND JUNCTION | ||||||||
State: | CO | ||||||||
PostalCode: | 815066065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702451211 | ||||||||
FaxNumber: | 9702454437 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2006 | ||||||||
LastUpdateDate: | 03/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POTTER | ||||||||
AuthorizedOfficialFirstName: | KATHERINE | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6177998387 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FIVE STAR QUALITY CARE-COLORADO LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1144 | CO | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 58301747 | 05 | CO |   | MEDICAID |