Healthcare Provider Details

I. General information

NPI: 1376142117
Provider Name (Legal Business Name): GARDEN RANCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5075 SADDLE DR
COLORADO SPRINGS CO
80918-3627
US

IV. Provider business mailing address

5075 SADDLE DR
COLORADO SPRINGS CO
80918-3627
US

V. Phone/Fax

Practice location:
  • Phone: 719-260-9121
  • Fax:
Mailing address:
  • Phone: 719-260-9121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: CHARISSA RICHARDSON
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 719-920-0166