Provider Demographics
NPI:1437219508
Name:COLONIAL MANOR LLC
Entity Type:Organization
Organization Name:COLONIAL MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:ATCHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-471-5541
Mailing Address - Street 1:907 W MALONE AVE
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-2425
Mailing Address - Country:US
Mailing Address - Phone:573-471-5541
Mailing Address - Fax:573-471-3063
Practice Address - Street 1:907 W MALONE AVE
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-2425
Practice Address - Country:US
Practice Address - Phone:573-471-5541
Practice Address - Fax:573-471-3063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320600000X320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266744804Medicaid