Healthcare Provider Details

I. General information

NPI: 1669807731
Provider Name (Legal Business Name): 1111 BONFORTE OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 HUNTER DR
PUEBLO CO
81001-1867
US

IV. Provider business mailing address

2668 NORTHPARK DR SUITE 220
LAFAYETTE CO
80026-3199
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-5911
  • Fax: 719-253-3709
Mailing address:
  • Phone: 303-952-9216
  • Fax: 303-675-5659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: DEAN KIKLIS
Title or Position: CFO
Credential:
Phone: 303-952-9216