Healthcare Provider Details

I. General information

NPI: 1033659669
Provider Name (Legal Business Name): COLONIAL CLUB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 BLANKENHEIM LN
SUN PRAIRIE WI
53590-2373
US

IV. Provider business mailing address

301 BLANKENHEIM LN
SUN PRAIRIE WI
53590-2373
US

V. Phone/Fax

Practice location:
  • Phone: 608-837-4611
  • Fax: 608-837-9302
Mailing address:
  • Phone: 608-837-4611
  • Fax: 608-837-9302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number265-800
License Number StateWI

VIII. Authorized Official

Name: MELODY RIEDEL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 608-837-4611