MEDICARE: MID-STATES SENIOR LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1063710432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-STATES SENIOR LIVING LLC

Provider Business Mailing Address
First Line	:	400 W MIDLAND AVE
Second Line	:	POB 5430
City	:	WOODLAND PARK
State	:	CO
Zip	:	80863-3144
Country	:	US
Telephone Number	:	719-686-8140
Fax Number	:	719-686-8141

Provider Business Practice Location Address
First Line	:	400 W MIDLAND AVE
Second Line	:	POB 5430
City	:	WOODLAND PARK
State	:	CO
Zip	:	80863-3144
Country	:	US
Telephone Number	:	719-686-8140
Fax Number	:	719-686-8141

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	ROBERT CHARLES SCHLEICHER
Credential	:
Telephone Number	:	719-314-7522

Provider Enumeration Date	:	03/08/2011
Last Update Date	:	03/08/2011

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