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General NPI Number Information
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NPI Number | 1164695656
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Entity Type | Organization
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Legal Business Name | LAKEWOOD HOMESTEAD LTD
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Dates
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Enumeration Date | 04/07/2008
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Last Update Date | 04/07/2008
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Provider Practice Location Address
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Address Line | 2121 WADSWORTH BLVD
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City | LAKEWOOD
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State | CO
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Zip | 80214-5706
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Country | US
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Telephone | 303-233-2121
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Fax |
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Provider Business Mailing Address
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Address Line | 2121 WADSWORTH BLVD.
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City | LAKEWOOD
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State | CO
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Zip | 80214-5706
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MR. RANDY BRIDGE
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Credential |
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Telephone | 303-233-2121
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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 | AL-0425
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License Number State | CO
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