1790123669 NPI number — MADISON SENIOR LIVING MANAGEMENT LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790123669 NPI number — MADISON SENIOR LIVING MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADISON SENIOR LIVING MANAGEMENT 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:
GRACE MANOR CARE CENTER
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:
1790123669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
465 5TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-346-7512
Provider Business Mailing Address Fax Number:
719-346-9373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
465 5TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-346-7512
Provider Business Practice Location Address Fax Number:
719-346-9373
Provider Enumeration Date:
06/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KIKLIS
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
303-952-9216

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , 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: 12601748 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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