Basic Information
| Provider Information | |||||||||
| NPI: | 1699156513 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLONIAL SCC LLC | ||||||||
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| OtherOrganizationName: | SCC OF COLONIAL OAKS REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 N PEARL ST | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752012822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142527600 | ||||||||
| FaxNumber: | 2142527704 | ||||||||
| Practice Location | |||||||||
| Address1: | 4921 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711124522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187425420 | ||||||||
| FaxNumber: | 3187425420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2015 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | BEAL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2142527600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1510688 | 05 | LA | MEDICAID | 19-5604 | 01 | LA | MEDICARE PART A | OTHER |