Healthcare Provider Details

I. General information

NPI: 1720179898
Provider Name (Legal Business Name): COLONIAL POPLIN NURSING HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 MAIN ST
FREMONT NH
03044-3434
US

IV. Provider business mailing address

P. O. BOX 101 442 MAIN ST
FREMONT NH
03044-3434
US

V. Phone/Fax

Practice location:
  • Phone: 603-895-3126
  • Fax: 603-895-3662
Mailing address:
  • Phone: 603-895-3126
  • Fax: 603-895-3662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number02393
License Number StateNH

VIII. Authorized Official

Name: MR. JEFFREY PHILBRICK
Title or Position: OWNER/PRESIDENT
Credential: ADMINISTRATOR
Phone: 603-895-3126