Provider Demographics
NPI:1518095223
Name:COLONIAL RETIREMENT CENTER INC.
Entity Type:Organization
Organization Name:COLONIAL RETIREMENT CENTER INC.
Other - Org Name:COLONIAL RESIDENTIAL CARE FACILITY II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-734-2846
Mailing Address - Street 1:1162 CEDAR STREET
Mailing Address - Street 2:P.O.BOX 727
Mailing Address - City:BISMARCK
Mailing Address - State:MO
Mailing Address - Zip Code:63624-0727
Mailing Address - Country:US
Mailing Address - Phone:573-734-2846
Mailing Address - Fax:573-734-2008
Practice Address - Street 1:1162 CEDAR STREET
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:MO
Practice Address - Zip Code:63624-0727
Practice Address - Country:US
Practice Address - Phone:573-734-2846
Practice Address - Fax:573-734-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032375310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2667449911Medicaid