Provider Demographics
NPI:1003817321
Name:COLONIAL REST HOME INC
Entity Type:Organization
Organization Name:COLONIAL REST HOME INC
Other - Org Name:THE CARRIAGE HOUSE OF BAY CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-684-2303
Mailing Address - Street 1:2394 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-9402
Mailing Address - Country:US
Mailing Address - Phone:989-684-2303
Mailing Address - Fax:989-684-2849
Practice Address - Street 1:2394 MIDLAND RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-9402
Practice Address - Country:US
Practice Address - Phone:989-684-2303
Practice Address - Fax:989-684-2849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI094010310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2080190Medicaid
MI2080190Medicaid