Provider Demographics
NPI:1992790802
Name:COLONIAL TERRACE INTERMEDIATE CARE, INC.
Entity type:Organization
Organization Name:COLONIAL TERRACE INTERMEDIATE CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SKAGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-926-9355
Mailing Address - Street 1:725 HARVARD DR
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-6185
Mailing Address - Country:US
Mailing Address - Phone:270-926-9355
Mailing Address - Fax:270-684-6283
Practice Address - Street 1:142 ROGER POWELL RD
Practice Address - Street 2:
Practice Address - City:SEBREE
Practice Address - State:KY
Practice Address - Zip Code:42455-2115
Practice Address - Country:US
Practice Address - Phone:270-835-2533
Practice Address - Fax:270-853-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100440314000000X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12501789Medicaid
KY0496390001Medicare NSC
KY12501789Medicaid