Provider Demographics
NPI:1386639078
Name:COLONIAL MANOR HEALTH CARE CENTER, INC.
Entity Type:Organization
Organization Name:COLONIAL MANOR HEALTH CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:SNOWBARGER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:419-994-4191
Mailing Address - Street 1:747 S MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUDONVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44842-1416
Mailing Address - Country:US
Mailing Address - Phone:419-994-4191
Mailing Address - Fax:
Practice Address - Street 1:747 S MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:LOUDONVILLE
Practice Address - State:OH
Practice Address - Zip Code:44842-1416
Practice Address - Country:US
Practice Address - Phone:419-994-4191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2482314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0297807Medicaid
OH365755Medicare ID - Type UnspecifiedMEDICARE