Provider Demographics
NPI:1558787036
Name:COLONIAL MANOR HEALTH CARE LLC
Entity Type:Organization
Organization Name:COLONIAL MANOR HEALTH CARE LLC
Other - Org Name:COLONIAL MANOR MEDICAL AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUDAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BIENSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-631-3000
Mailing Address - Street 1:1010 E WAUSAU AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3101
Mailing Address - Country:US
Mailing Address - Phone:715-842-2028
Mailing Address - Fax:715-845-5810
Practice Address - Street 1:1010 E WAUSAU AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-3101
Practice Address - Country:US
Practice Address - Phone:715-842-2028
Practice Address - Fax:715-845-5810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-09
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI525405Medicare Oscar/Certification