Provider Demographics
NPI:1699149401
Name:HAVEN OF CARE ASSISTED LIVING AT ARGONNE, LLC
Entity type:Organization
Organization Name:HAVEN OF CARE ASSISTED LIVING AT ARGONNE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MEGAWATI
Authorized Official - Middle Name:
Authorized Official - Last Name:WIRANTONO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-947-7392
Mailing Address - Street 1:PO BOX 461284
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80046-1284
Mailing Address - Country:US
Mailing Address - Phone:303-947-7392
Mailing Address - Fax:303-400-5159
Practice Address - Street 1:3920 S ARGONNE WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-3602
Practice Address - Country:US
Practice Address - Phone:303-947-7392
Practice Address - Fax:303-400-5159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23M127310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21658358Medicaid