Provider Demographics
NPI:1285852798
Name:COLONIAL VILLAGE LV PROPERTY, LTD
Entity Type:Organization
Organization Name:COLONIAL VILLAGE LV PROPERTY, LTD
Other - Org Name:COLONIAL VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAID COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-758-6332
Mailing Address - Street 1:3723 FAIRVIEW INDUSTRIAL DR SE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1177
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2910 N EASTMAN RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5029
Practice Address - Country:US
Practice Address - Phone:903-758-6332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility