MEDICARE: PMG OPCO-COLONIAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1124589544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PMG OPCO-COLONIAL LLC

Provider Business Mailing Address
First Line	:	4921 MEDICAL DR
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71112-4522
Country	:	US
Telephone Number	:	318-742-5420
Fax Number	:	318-742-8887

Provider Business Practice Location Address
First Line	:	4921 MEDICAL DR
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71112-4522
Country	:	US
Telephone Number	:	318-742-5420
Fax Number	:	318-742-8887

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	STEVEN BOULWARE
Credential	:
Telephone Number	:	972-428-0900

Provider Enumeration Date	:	03/28/2019
Last Update Date	:	03/28/2019

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