Provider Demographics
NPI:1831686765
Name:COLONIAL MANAGEMENT GROUP
Entity type:Organization
Organization Name:COLONIAL MANAGEMENT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS
Authorized Official - Phone:727-544-0044
Mailing Address - Street 1:8800 49TH ST N STE 106
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-5332
Mailing Address - Country:US
Mailing Address - Phone:727-544-0044
Mailing Address - Fax:
Practice Address - Street 1:8800 49TH ST N STE 106
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-5332
Practice Address - Country:US
Practice Address - Phone:727-544-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone