1104368000 NPI number — THE MARY SANDOE HOUSE, INC

Table of content: (NPI 1104368000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104368000 NPI number — THE MARY SANDOE HOUSE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MARY SANDOE HOUSE, INC
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:
Provider Other Organization Name Type Code:
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:
1104368000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1244 GILLASPIE DR
Provider Second Line Business Mailing Address:
1242 GILLASPIE DRIVE
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80305-6600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-494-7317
Provider Business Mailing Address Fax Number:
303-494-0653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1244 GILLASPIE DR
Provider Second Line Business Practice Location Address:
1242 GILLASPIE DRIVE
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80305-6600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-494-7317
Provider Business Practice Location Address Fax Number:
303-494-0653
Provider Enumeration Date:
11/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LONGOBARDI
Authorized Official First Name:
DOROTHY
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
303-494-7317

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  230354 , 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: 04181251 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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