Basic Information
| Provider Information | |||||||||
| NPI: | 1184756173 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLONIAL NURSING AND REHABILITATION CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 S BUREAU VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613562203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158753347 | ||||||||
| FaxNumber: | 8158752012 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 S BUREAU VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613562203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158753347 | ||||||||
| FaxNumber: | 8158752012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | STEINBERG | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8479053000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 46227 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 50242 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |