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General NPI Number Information
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NPI Number | 1003273053
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Entity Type | Organization
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Legal Business Name | VILLA GROVE ASSISTED LIVING HOME
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Dates
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Enumeration Date | 01/21/2016
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Last Update Date | 01/21/2016
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Provider Practice Location Address
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Address Line | 715 E B ST
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City | PUEBLO
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State | CO
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Zip | 81003-3504
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Country | US
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Telephone | 719-544-1561
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Fax | 719-542-6539
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Provider Business Mailing Address
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Address Line | 715 E B ST
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City | PUEBLO
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State | CO
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Zip | 81003-3504
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Country | US
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Telephone | 719-544-1561
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Fax | 719-542-6539
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Authorized Official
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Title or Position | VICE-PRESIDENT
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Name | PAUL SPICOLA
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Credential |
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Telephone | 719-369-4567
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 23W276
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License Number State | CO
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