Basic Information
Provider Information | |||||||||
NPI: | 1598719312 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEAK MEDICAL COLORADO NO. 2, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PUEBLO CARE AND REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 SUN AVE NE | ||||||||
Address2: | COMPLIANCE DEPARTMENT | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871094373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5054685604 | ||||||||
FaxNumber: | 5054684681 | ||||||||
Practice Location | |||||||||
Address1: | 2611 JONES AVE | ||||||||
Address2: |   | ||||||||
City: | PUEBLO | ||||||||
State: | CO | ||||||||
PostalCode: | 810042650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195641735 | ||||||||
FaxNumber: | 7195641501 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 07/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERG | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | T. | ||||||||
AuthorizedOfficialTitleorPosition: | VP ASSISTANT SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 5054684742 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SUNBRIDGE HEALTHCARE LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0485 | CO | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 60052279 | 05 | CO |   | MEDICAID |