Provider Demographics
NPI:1407042567
Name:COLWELL INTEREST, INC.
Entity Type:Organization
Organization Name:COLWELL INTEREST, INC.
Other - Org Name:POLAND COMMUNITY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:COLWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-442-2284
Mailing Address - Street 1:1111 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-6423
Mailing Address - Country:US
Mailing Address - Phone:318-442-2284
Mailing Address - Fax:318-448-1427
Practice Address - Street 1:3004 HIGHWAY 457
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71302-9255
Practice Address - Country:US
Practice Address - Phone:318-442-5266
Practice Address - Fax:318-442-5266
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLWELL INTEREST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-21
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA485320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1717169Medicaid