=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639701600
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLONIAL PARK ADULT ASSISTED LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2020
-----------------------------------------------------
Last Update Date | 02/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 W COLONIAL PARK DR
-----------------------------------------------------
City | GRAND LEDGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48837-2215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-526-1195
-----------------------------------------------------
Fax | 517-626-2525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13282 S HINMAN RD
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48822-9637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-526-1195
-----------------------------------------------------
Fax | 517-626-2525
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. LORRAINE ADELE MORALES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-526-1195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------