Healthcare Provider Details

I. General information

NPI: 1609996560
Provider Name (Legal Business Name): SSC BOULDER OPERATING COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2007
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4685 BASELINE RD
BOULDER CO
80303-2601
US

IV. Provider business mailing address

5300 W SAM HOUSTON PKWY N SUITE 100
HOUSTON TX
77041-5161
US

V. Phone/Fax

Practice location:
  • Phone: 303-494-0535
  • Fax:
Mailing address:
  • Phone: 832-467-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1285
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier06934242
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: KELLE C SANTORO
Title or Position: SR DIRECTOR AR
Credential:
Phone: 832-467-5728