Provider Demographics
NPI:1396800389
Name:MSHC COLONIAL LODGE LLC
Entity type:Organization
Organization Name:MSHC COLONIAL LODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:POWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-534-8667
Mailing Address - Street 1:1901 RICKETY LN
Mailing Address - Street 2:STE 208
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1702
Mailing Address - Country:US
Mailing Address - Phone:903-534-8667
Mailing Address - Fax:903-509-0026
Practice Address - Street 1:5001 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2913
Practice Address - Country:US
Practice Address - Phone:903-792-0838
Practice Address - Fax:903-793-4562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114502310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0010136550OtherCBA CONTRACT