Provider Demographics
NPI:1598974636
Name:COLONY MANOR ASSISTED LIVING HOMES
Entity Type:Organization
Organization Name:COLONY MANOR ASSISTED LIVING HOMES
Other - Org Name:COLONY MANOR ASSISTED LIVING HOMES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-373-1880
Mailing Address - Street 1:PO BOX 870469
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687
Mailing Address - Country:US
Mailing Address - Phone:907-373-1880
Mailing Address - Fax:907-373-1820
Practice Address - Street 1:6801 WESWOOD DR
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-373-1880
Practice Address - Fax:907-373-1820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK000196310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL9797Medicaid