Provider Demographics
NPI:1902430408
Name:LODGE ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:LODGE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AIME
Authorized Official - Suffix:
Authorized Official - Credentials:RN-BSNA
Authorized Official - Phone:719-391-4444
Mailing Address - Street 1:1900 E PIKES PEAK AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5862
Mailing Address - Country:US
Mailing Address - Phone:719-391-4444
Mailing Address - Fax:
Practice Address - Street 1:1420 E FOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3502
Practice Address - Country:US
Practice Address - Phone:719-695-0969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility