1891882957 NPI number — SOUTH PUEBLO MEDICAL INVESTORS, LLC

Table of content: (NPI 1891882957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891882957 NPI number — SOUTH PUEBLO MEDICAL INVESTORS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH PUEBLO MEDICAL INVESTORS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIFE CARE CENTER OF PUEBLO
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891882957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 KEITH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37312-3713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-473-5751
Provider Business Mailing Address Fax Number:
423-339-8342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2118 CHATALET LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81005-4625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-564-2000
Provider Business Practice Location Address Fax Number:
719-564-7741
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CROSS
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
423-473-5867

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0600 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05650742 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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