MEDICARE: COLONIAL SCC 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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	19-5604	OTHER	LA	MEDICARE PART A

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699156513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLONIAL SCC LLC

Provider Business Mailing Address
First Line	:	600 N PEARL ST
Second Line	:	SUITE 1100
City	:	DALLAS
State	:	TX
Zip	:	75201-2822
Country	:	US
Telephone Number	:	214-252-7600
Fax Number	:	214-252-7704

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	:	318-742-5420

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MICHAEL BEAL
Credential	:
Telephone Number	:	214-252-7600

Provider Enumeration Date	:	06/16/2015
Last Update Date	:	03/03/2020

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Directions to “COLONIAL SCC LLC ” Practice Location

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