Healthcare Provider Details

I. General information

NPI: 1417310509
Provider Name (Legal Business Name): IDYLLWOOD MANOR AT ANDES CT., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5286 S ANDES CT
CENTENNIAL CO
80015-4896
US

IV. Provider business mailing address

PO BOX 2253
PARKER CO
80134-1414
US

V. Phone/Fax

Practice location:
  • Phone: 303-513-4784
  • Fax: 303-799-5837
Mailing address:
  • Phone: 303-513-4784
  • Fax: 303-799-5837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number23V725
License Number StateCO

VIII. Authorized Official

Name: BOB MANZI
Title or Position: MEMBER
Credential:
Phone: 303-513-4784