Healthcare Provider Details

I. General information

NPI: 1114085875
Provider Name (Legal Business Name): STATE OF COLORADO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3749 SHERMAN AVE
MONTE VISTA CO
81144-9403
US

IV. Provider business mailing address

PO BOX 97
HOMELAKE CO
81135-0097
US

V. Phone/Fax

Practice location:
  • Phone: 719-852-5118
  • Fax: 719-852-3881
Mailing address:
  • Phone: 719-852-5118
  • Fax: 719-852-3881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2023
License Number StateCO

VIII. Authorized Official

Name: MS. MINDY MONTAGUE
Title or Position: ADMINISTRATOR
Credential:
Phone: 719-852-5118