Provider Demographics
NPI:1497733307
Name:COLONIAL HEALTH CARE CENTER,LLC DBA ST. JOSEPHS'S HEALTH CARE CENTER
Entity Type:Organization
Organization Name:COLONIAL HEALTH CARE CENTER,LLC DBA ST. JOSEPHS'S HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONERWAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:313-664-1031
Mailing Address - Street 1:9400 CONANT ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3538
Mailing Address - Country:US
Mailing Address - Phone:313-664-1031
Mailing Address - Fax:
Practice Address - Street 1:9400 CONANT ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3538
Practice Address - Country:US
Practice Address - Phone:313-664-1031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI824340314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4614268Medicaid
MI09680OtherBC/BS ID
MI4614268Medicaid