Provider Demographics
NPI:1679089197
Name:ASSISTED LIVING AT SPRING, LLC
Entity type:Organization
Organization Name:ASSISTED LIVING AT SPRING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:SETIAWAN
Authorized Official - Last Name:SIAUW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-934-4950
Mailing Address - Street 1:PO BOX 274
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-0274
Mailing Address - Country:US
Mailing Address - Phone:720-934-4950
Mailing Address - Fax:720-420-1322
Practice Address - Street 1:1605 JET WING DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916-2258
Practice Address - Country:US
Practice Address - Phone:719-434-7042
Practice Address - Fax:719-434-8580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23D512310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility