Provider Demographics
NPI:1568755577
Name:RANDOLPH HEALTHCARE, INC.
Entity Type:Organization
Organization Name:RANDOLPH HEALTHCARE, INC.
Other - Org Name:COLONIAL MANOR OF RANDOLPH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MS
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:811 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NE
Mailing Address - Zip Code:68771-1706
Mailing Address - Country:US
Mailing Address - Phone:402-337-0444
Mailing Address - Fax:402-337-1746
Practice Address - Street 1:811 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NE
Practice Address - Zip Code:68771-1706
Practice Address - Country:US
Practice Address - Phone:402-337-0444
Practice Address - Fax:402-337-1746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE310400000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE285183Medicare Oscar/Certification