Healthcare Provider Details

I. General information

NPI: 1992790802
Provider Name (Legal Business Name): COLONIAL TERRACE INTERMEDIATE CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 ROGER POWELL RD
SEBREE KY
42455-2115
US

IV. Provider business mailing address

725 HARVARD DR
OWENSBORO KY
42301-6185
US

V. Phone/Fax

Practice location:
  • Phone: 270-835-2533
  • Fax: 270-853-9004
Mailing address:
  • Phone: 270-926-9355
  • Fax: 270-684-6283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100440
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number100440
License Number StateKY

VIII. Authorized Official

Name: MR. TERRY LYNN SKAGGS
Title or Position: CFO
Credential:
Phone: 270-926-9355