Provider Demographics
NPI:1104037985
Name:PETERSON COLONIAL HOMES, INC.
Entity Type:Organization
Organization Name:PETERSON COLONIAL HOMES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:SCHRAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-878-0642
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:BROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:55711-0350
Mailing Address - Country:US
Mailing Address - Phone:218-878-0642
Mailing Address - Fax:218-878-2978
Practice Address - Street 1:4723 NYGAARD ROAD
Practice Address - Street 2:
Practice Address - City:BROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:55711-0350
Practice Address - Country:US
Practice Address - Phone:218-878-0642
Practice Address - Fax:218-878-2978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00213104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness