Provider Demographics
NPI:1639701600
Name:COLONIAL PARK ADULT ASSISTED LIVING
Entity Type:Organization
Organization Name:COLONIAL PARK ADULT ASSISTED LIVING
Other - Org Name:EAGLES NEST ADULT ASSISTED LIVING
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:ADELE
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-526-1195
Mailing Address - Street 1:13282 S HINMAN RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:MI
Mailing Address - Zip Code:48822-9637
Mailing Address - Country:US
Mailing Address - Phone:517-526-1195
Mailing Address - Fax:517-626-2525
Practice Address - Street 1:1050 W COLONIAL PARK DR
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-2215
Practice Address - Country:US
Practice Address - Phone:517-526-1195
Practice Address - Fax:517-626-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-07
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency