Provider Demographics
NPI:1780688234
Name:COLONIAL HOME CARE
Entity Type:Organization
Organization Name:COLONIAL HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:702-733-8533
Mailing Address - Street 1:3530 E FLAMINGO RD
Mailing Address - Street 2:STE 270
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5092
Mailing Address - Country:US
Mailing Address - Phone:702-733-8533
Mailing Address - Fax:702-733-8498
Practice Address - Street 1:3530 E FLAMINGO RD
Practice Address - Street 2:STE 270
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5092
Practice Address - Country:US
Practice Address - Phone:702-733-8533
Practice Address - Fax:702-733-8498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV524HHA-10251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV297085Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER