1306231642 NPI number — MESA VIEW RETIREMENT HOME INC.

Table of content: (NPI 1306231642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306231642 NPI number — MESA VIEW RETIREMENT HOME INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MESA VIEW RETIREMENT HOME 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:
1306231642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16200 ROAD 31
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCOS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-749-0356
Provider Business Mailing Address Fax Number:
970-882-7997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24760 COUNTY ROAD G
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORTEZ
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-564-0716
Provider Business Practice Location Address Fax Number:
970-564-9156
Provider Enumeration Date:
04/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WARREN
Authorized Official First Name:
INA
Authorized Official Middle Name:
LUJEANE
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
970-749-0356

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  231289 , 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: 04182176 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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