Provider Demographics
NPI:1992790075
Name:OCOEE COLBY HEALTHCARE CENTER LLC
Entity type:Organization
Organization Name:OCOEE COLBY HEALTHCARE CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-618-1488
Mailing Address - Street 1:3915 ADKISSON DR NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-2821
Mailing Address - Country:US
Mailing Address - Phone:423-834-3188
Mailing Address - Fax:
Practice Address - Street 1:702 W DOLF ST
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:WI
Practice Address - Zip Code:54421-9604
Practice Address - Country:US
Practice Address - Phone:715-223-2352
Practice Address - Fax:859-281-5150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3080314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20191800Medicaid
WI525360Medicare Oscar/Certification
5771870001Medicare NSC