Basic Information
| Provider Information | |||||||||
| NPI: | 1649261827 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLONIAL HEALTH CARE CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. JOSEPH'S HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 W LUNT AVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLNWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607122615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474402660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9400 CONANT ST | ||||||||
| Address2: | |||||||||
| City: | HAMTRAMCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482123538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138744500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | LEONARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8476747600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 82-4340 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 60/4614268 | 05 | MI | MEDICAID |