Provider Demographics
NPI:1225036478
Name:COLONIAL PARK CARE CENTER, LLC
Entity Type:Organization
Organization Name:COLONIAL PARK CARE CENTER, LLC
Other - Org Name:COLONIAL PARK CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:HENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-963-9150
Mailing Address - Street 1:209 SIGMA DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-2826
Mailing Address - Country:US
Mailing Address - Phone:412-963-9150
Mailing Address - Fax:412-963-6676
Practice Address - Street 1:800 KING RUSS RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5101
Practice Address - Country:US
Practice Address - Phone:717-657-1520
Practice Address - Fax:717-657-3624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA640202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000000153034OtherUNISON MEDPLUS
PA000000153034OtherUNISON ADVANTAGE
PA1009101610001Medicaid
PA0129OtherHIGHMARK BLUE CROSS
PA395395OtherHIGHMARK BLUE SHIELD
PA000000153034OtherUNISON ADULTBASIC
PA000000153034OtherUNISON KIDS
PA395395OtherHIGHMARK BLUE SHIELD
PA000000153034OtherUNISON MEDPLUS
PA000000153034OtherUNISON KIDS
PA=========OtherHEALTH ASSURANCE
PA1009101610001Medicaid
PA1009101610001Medicaid