Provider Demographics
NPI:1487143996
Name:BIRCH ASSISTED LIVING
Entity type:Organization
Organization Name:BIRCH ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-296-0724
Mailing Address - Street 1:1819 BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-6142
Mailing Address - Country:US
Mailing Address - Phone:720-296-0724
Mailing Address - Fax:
Practice Address - Street 1:1819 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-6142
Practice Address - Country:US
Practice Address - Phone:970-346-1150
Practice Address - Fax:970-346-1151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23Y767310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23Y767OtherASSISTED LIVING