Healthcare Provider Details

I. General information

NPI: 1275174567
Provider Name (Legal Business Name): COLONIAL HEIGHTS OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 E ELLERSLIE AVE
COLONIAL HEIGHTS VA
23834-1720
US

IV. Provider business mailing address

831 E ELLERSLIE AVE
COLONIAL HEIGHTS VA
23834-1720
US

V. Phone/Fax

Practice location:
  • Phone: 804-526-6851
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: ELAZAR FISCHER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 804-526-6851