Healthcare Provider Details

I. General information

NPI: 1306822077
Provider Name (Legal Business Name): COLONIAL VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 PARK AVE PLAZA
CONTOOCOOK NH
03229-0338
US

IV. Provider business mailing address

PO BOX 338
CONTOOCOOK NH
03229-0338
US

V. Phone/Fax

Practice location:
  • Phone: 630-746-4600
  • Fax: 603-746-4117
Mailing address:
  • Phone: 603-746-5085
  • Fax: 603-746-4117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0101
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MARC REAL FOURNIER
Title or Position: PRESIDENT CEO
Credential:
Phone: 603-746-5085