Provider Demographics
NPI:1164411187
Name:COLONIAL MANOR LTC, LLC
Entity Type:Organization
Organization Name:COLONIAL MANOR LTC, LLC
Other - Org Name:COLONIAL NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:SLYK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD FASCP
Authorized Official - Phone:330-424-3721
Mailing Address - Street 1:1528 MARKET AVE N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44714-2695
Mailing Address - Country:US
Mailing Address - Phone:330-453-8466
Mailing Address - Fax:330-453-1424
Practice Address - Street 1:1528 MARKET AVE N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-2695
Practice Address - Country:US
Practice Address - Phone:330-453-8466
Practice Address - Fax:330-453-1424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3620313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0177544Medicaid
OH2635938Medicaid
OH0177544Medicaid