Provider Demographics
NPI:1275739450
Name:OMNI MANOR, INC.
Entity Type:Organization
Organization Name:OMNI MANOR, INC.
Other - Org Name:LIBERTY ARMS ASSISTED LIVING RESIDENCE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:330-759-2893
Mailing Address - Street 1:1353 CHURCHILL HUBBARD RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1380
Mailing Address - Country:US
Mailing Address - Phone:330-759-2893
Mailing Address - Fax:330-759-2920
Practice Address - Street 1:1353 CHURCHILL HUBBARD RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1380
Practice Address - Country:US
Practice Address - Phone:330-759-2893
Practice Address - Fax:330-759-2920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5639310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2113ROtherSTATE FACILITY NUMBER
OH5639OtherSTATE LICENSE NUMBER