MEDICARE: PARENT CARE LIFE INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311Z00000X	Custodial Care Facility	23G509	CO
2	311ZA0620X	Adult Care Home Facility	23G509	CO
3	310400000X	Assisted Living Facility	23G509	CO

General Provider Information

NPI Number	:	1114203601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARENT CARE LIFE INC.

Provider Business Mailing Address
First Line	:	1414 N HANCOCK AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-2655
Country	:	US
Telephone Number	:	719-473-6339
Fax Number	:	719-448-9301

Provider Business Practice Location Address
First Line	:	1417 E BUENA VENTURA ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-2824
Country	:	US
Telephone Number	:	719-473-6339
Fax Number	:	719-448-9301

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. RICKY LEE SIMPSON
Credential	:
Telephone Number	:	719-473-6339

Provider Enumeration Date	:	10/27/2011
Last Update Date	:	10/27/2011

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