Provider Demographics
NPI:1699772533
Name:SSC COLONIAL COLUMNS CS OPERATING LLC
Entity type:Organization
Organization Name:SSC COLONIAL COLUMNS CS OPERATING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:SHINN
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:719-473-1105
Mailing Address - Street 1:1340 E FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6433
Mailing Address - Country:US
Mailing Address - Phone:719-473-1105
Mailing Address - Fax:719-473-0495
Practice Address - Street 1:1340 E FILLMORE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6433
Practice Address - Country:US
Practice Address - Phone:719-473-1105
Practice Address - Fax:719-473-0495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0427311500000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05654793Medicaid
CO065225Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER