Provider Demographics
NPI:1053801712
Name:STARLIGHT ASSISTED LIVING
Entity type:Organization
Organization Name:STARLIGHT ASSISTED LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GULTOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-409-7130
Mailing Address - Street 1:19053 E 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80249-8433
Mailing Address - Country:US
Mailing Address - Phone:720-409-7130
Mailing Address - Fax:719-390-4721
Practice Address - Street 1:68 SECURITY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911-1929
Practice Address - Country:US
Practice Address - Phone:719-390-4721
Practice Address - Fax:719-390-4721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO230550310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility