Provider Demographics
NPI:1316302664
Name:VILLA GROVE ASSISTED LIVING
Entity type:Organization
Organization Name:VILLA GROVE ASSISTED LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SPICOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-369-4567
Mailing Address - Street 1:403 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2748
Mailing Address - Country:US
Mailing Address - Phone:719-543-0305
Mailing Address - Fax:719-562-9684
Practice Address - Street 1:403 W 13TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2748
Practice Address - Country:US
Practice Address - Phone:719-543-0305
Practice Address - Fax:719-562-9684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2306023104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26420554Medicaid