1942391875 NPI number — EAGLE RIDGE OPERATING COMPANY, LLC

Table of content: (NPI 1942391875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942391875 NPI number — EAGLE RIDGE OPERATING COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE RIDGE OPERATING COMPANY, 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:
EAGLE RIDGE AT GRAND VALLEY
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:
1942391875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12136 W. BAYAUD AVENUE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-974-6278
Provider Business Mailing Address Fax Number:
303-987-0434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2425 TELLER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND JUNCTION
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81501-5141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-243-3381
Provider Business Practice Location Address Fax Number:
970-243-3416
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KORETKE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF REIMBURSEMENT
Authorized Official Telephone Number:
720-974-6278

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  021116 , 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: 417-081058 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1300-86863 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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