Healthcare Provider Details

I. General information

NPI: 1124485933
Provider Name (Legal Business Name): 33 SOUTHMOOR PROPERTIES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 FENTON ST
WHEAT RIDGE CO
80214-8116
US

IV. Provider business mailing address

2920 FENTON ST
WHEAT RIDGE CO
80214-8116
US

V. Phone/Fax

Practice location:
  • Phone: 303-238-0481
  • Fax: 303-233-3775
Mailing address:
  • Phone: 303-238-0481
  • Fax: 303-233-3775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number020436
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier34376020
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

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