Organization
COLBY LAKE CARE HOME, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. VIJWANTIE SIRJU LPN (CEO/OWNER)
(651) 230-5088
Entity
Organization
Contact information
Practice address
9377 NEWCASTLE RD, WOODBURY, MN 55125-3717
(651) 230-5088
Mailing address
9377 NEWCASTLE RD, WOODBURY, MN 55125-3717
(651) 230-5088
Taxonomy
Speciality
Code
Description
License number
State
311ZA0620X
Adult Care Home Facility
Primary
1047414-2-AFC
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
A814673100
—
MN
Enumeration date
12/09/2008
Last updated
12/09/2008
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