Provider Demographics
NPI:1396980017
Name:COLBY LAKE CARE HOME, INC.
Entity type:Organization
Organization Name:COLBY LAKE CARE HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:VIJWANTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIRJU
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:651-230-5088
Mailing Address - Street 1:9377 NEWCASTLE RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3717
Mailing Address - Country:US
Mailing Address - Phone:651-230-5088
Mailing Address - Fax:
Practice Address - Street 1:9377 NEWCASTLE RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3717
Practice Address - Country:US
Practice Address - Phone:651-230-5088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1047414-2-AFC311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA814673100Medicaid