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General NPI Number Information
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NPI Number | 1396980017
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Entity Type | Organization
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Legal Business Name | COLBY LAKE CARE HOME, INC.
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Dates
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Enumeration Date | 12/09/2008
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Last Update Date | 12/09/2008
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Provider Practice Location Address
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Address Line | 9377 NEWCASTLE RD
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City | WOODBURY
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State | MN
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Zip | 55125-3717
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Country | US
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Telephone | 651-230-5088
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Fax |
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Provider Business Mailing Address
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Address Line | 9377 NEWCASTLE RD
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City | WOODBURY
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State | MN
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Zip | 55125-3717
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Country | US
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Telephone | 651-230-5088
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | MS. VIJWANTIE SIRJU
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Credential | LPN
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Telephone | 651-230-5088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | 1047414-2-AFC
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License Number State | MN
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