MEDICARE: GRAND JUNCTION WELLAGE PACIFICA, 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1619566072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND JUNCTION WELLAGE PACIFICA, LLC

Provider Business Mailing Address
First Line	:	2656 PATTERSON RD
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81506-8820
Country	:	US
Telephone Number	:	970-822-4141
Fax Number	:	970-245-0771

Provider Business Practice Location Address
First Line	:	2656 PATTERSON RD
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81506-8820
Country	:	US
Telephone Number	:	970-822-4141
Fax Number	:	970-245-0771

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

Provider Enumeration Date	:	01/11/2021
Last Update Date	:	01/11/2021

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