Provider Demographics
NPI:1902803620
Name:33 SOUTHMOOR PROPERTIES, INC.
Entity Type:Organization
Organization Name:33 SOUTHMOOR PROPERTIES, INC.
Other - Org Name:WHEATRIDGE MANOR NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOSKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:303-238-3838
Mailing Address - Street 1:2920 FENTON ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80214-8116
Mailing Address - Country:US
Mailing Address - Phone:303-238-0481
Mailing Address - Fax:303-233-3775
Practice Address - Street 1:2920 FENTON ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80214-8116
Practice Address - Country:US
Practice Address - Phone:303-238-0481
Practice Address - Fax:303-233-3775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO020436314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4540660001OtherDMERC NUMBER
CO80636217Medicaid
CO4540660001OtherDMERC NUMBER