Healthcare Provider Details

I. General information

NPI: 1487980082
Provider Name (Legal Business Name): COLONIAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2009
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 W US HIGHWAY 40
GREENFIELD IN
46140-8803
US

IV. Provider business mailing address

5430 W US HIGHWAY 40
GREENFIELD IN
46140-8803
US

V. Phone/Fax

Practice location:
  • Phone: 317-894-3301
  • Fax: 317-254-2510
Mailing address:
  • Phone: 317-894-3301
  • Fax: 317-254-2510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number09-000360-1
License Number StateIN

VIII. Authorized Official

Name: MRS. CYNTHIA RENE ROTH
Title or Position: CONTROLLER
Credential:
Phone: 317-557-1190