Provider Demographics
NPI:1861793457
Name:ANGKOR WAT EAST ASSISTED LIVING I
Entity type:Organization
Organization Name:ANGKOR WAT EAST ASSISTED LIVING I
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:LEM
Authorized Official - Last Name:HEAN
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:970-210-0292
Mailing Address - Street 1:207 RIVER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81503-3421
Mailing Address - Country:US
Mailing Address - Phone:970-210-0292
Mailing Address - Fax:970-434-7036
Practice Address - Street 1:3293 LOMBARDY LN
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:CO
Practice Address - Zip Code:81520-7717
Practice Address - Country:US
Practice Address - Phone:970-210-0292
Practice Address - Fax:970-434-7036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23U3213104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness