=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417830357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESTMOOR CARE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2025
-----------------------------------------------------
Last Update Date | 07/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 895 S MONACO PKWY
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80224-1501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-321-3110
-----------------------------------------------------
Fax | 303-321-1581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 895 S MONACO PKWY
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80224-1501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-321-3110
-----------------------------------------------------
Fax | 303-321-1581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, COST REPORTING
-----------------------------------------------------
Name | MARY KORETKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 720-974-6278
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------