Basic Information
Provider Information | |||||||||
NPI: | 1932697380 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SSC MONTROSE SAN JUAN OPERATING COMPANY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAN JUAN LIVING CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5300 W SAM HOUSTON PKWY N STE 100 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770415162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8624676000 | ||||||||
FaxNumber: | 8324678500 | ||||||||
Practice Location | |||||||||
Address1: | 1043 RIDGE ST | ||||||||
Address2: |   | ||||||||
City: | MONTROSE | ||||||||
State: | CO | ||||||||
PostalCode: | 814014423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702499683 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2018 | ||||||||
LastUpdateDate: | 05/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PITTS | ||||||||
AuthorizedOfficialFirstName: | KEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR REIMBURSEMENT SERVICES | ||||||||
AuthorizedOfficialTelephone: | 8324676793 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SSC MONTROSE SAN JUAN OPERATING COMPANY LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | 1300 | CO | Y |   | Respite Care Facility | Respite Care |   |
ID Information
ID | Type | State | Issuer | Description | 9000160358 | 05 | CO |   | MEDICAID |