Basic Information
| Provider Information | |||||||||
| NPI: | 1962493809 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUCKEYE A, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AUTUMN HEIGHTS HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12136 W. BAYAUD AVENUE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802282115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032383838 | ||||||||
| FaxNumber: | 3039870434 | ||||||||
| Practice Location | |||||||||
| Address1: | 3131 S. FEDERAL BLVD | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802362713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037610260 | ||||||||
| FaxNumber: | 3037617088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 05/25/2016 | ||||||||
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| AuthorizedOfficialLastName: | MOSKOWITZ | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3032383838 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0318 | CO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 05656004 | 05 | CO | MEDICAID |