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NPI Code Detail

MEDICARE: PINE RIDGE EXTEND CARE CENTER, LLC

MEDICARE: PINE RIDGE EXTEND CARE CENTER, LLC
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
1314000000XSkilled Nursing Facility0105CO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1245237494
Entity Type Code : Organization
Provider Name (Legal Business Name) : PINE RIDGE EXTEND CARE CENTER, LLC
Provider Business Mailing Address
First Line : 119 BASTILLE DR
Second Line :
City : PAGOSA SPRINGS
State : CO
Zip : 81147-9388
Country : US
Telephone Number : 970-731-4330
Fax Number : 970-731-4046
Provider Business Practice Location Address
First Line : 119 BASTILLE DR
Second Line :
City : PAGOSA SPRINGS
State : CO
Zip : 81147-9388
Country : US
Telephone Number : 970-731-4330
Fax Number : 970-731-4046
Authorized Official
Title or Position : NURSING HOME ADMINISTRATOR
Name : MARY J. BROOKS
Credential : RN
Telephone Number : 970-731-4330
Provider Enumeration Date : 07/01/2005
Last Update Date : 10/06/2015

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