Healthcare Provider Details

I. General information

NPI: 1043203631
Provider Name (Legal Business Name): QL-CAMBRIDGE CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 08/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1685 EATON ST
LAKEWOOD CO
80214-1628
US

IV. Provider business mailing address

1685 EATON ST
LAKEWOOD CO
80214-1628
US

V. Phone/Fax

Practice location:
  • Phone: 303-232-4405
  • Fax: 303-232-0805
Mailing address:
  • Phone: 303-232-4405
  • Fax: 303-232-0805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0355
License Number StateCO

VIII. Authorized Official

Name: MISS MARY KORETKE
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 303-238-3838