Healthcare Provider Details

I. General information

NPI: 1477905891
Provider Name (Legal Business Name): GREEN LAKEVIEW ADULT DAYCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2016
Last Update Date: 07/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9999 W 60TH AVE
ARVADA CO
80004-4949
US

IV. Provider business mailing address

9999 W 60TH AVE
ARVADA CO
80004-4949
US

V. Phone/Fax

Practice location:
  • Phone: 303-421-2914
  • Fax: 303-421-2915
Mailing address:
  • Phone: 303-421-2914
  • Fax: 303-421-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number20101564719
License Number StateCO

VIII. Authorized Official

Name: IVAN MUZYCHENKO
Title or Position: MANAGER
Credential:
Phone: 303-421-2914