Healthcare Provider Details

I. General information

NPI: 1588222863
Provider Name (Legal Business Name): 1111 BONFORTE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 HUNTER DR.
PUEBLO CO
81001
US

IV. Provider business mailing address

855 HUNTER DR.
PUEBLO CO
81001
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-5911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

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