Healthcare Provider Details

I. General information

NPI: 1548629066
Provider Name (Legal Business Name): PONDEROSA CARE COMMUNITIES A, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3185 W ARKANSAS AVE
DENVER CO
80219-4004
US

IV. Provider business mailing address

3185 W ARKANSAS AVE
DENVER CO
80219-4004
US

V. Phone/Fax

Practice location:
  • Phone: 303-922-1169
  • Fax: 303-934-0220
Mailing address:
  • Phone: 303-922-1169
  • Fax: 303-934-0220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number020413
License Number StateCO

VIII. Authorized Official

Name: MARY KORETKE
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 720-974-6278