Provider Demographics
NPI:1578501235
Name:COLONIAL MANOR NURSING HOME
Entity Type:Organization
Organization Name:COLONIAL MANOR NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-662-6646
Mailing Address - Street 1:403 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:56150-9573
Mailing Address - Country:US
Mailing Address - Phone:507-662-6646
Mailing Address - Fax:507-662-5531
Practice Address - Street 1:403 COLONIAL AVE
Practice Address - Street 2:
Practice Address - City:LAKEFIELD
Practice Address - State:MN
Practice Address - Zip Code:56150-9573
Practice Address - Country:US
Practice Address - Phone:507-662-6646
Practice Address - Fax:507-662-5531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331921314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9471COOtherBCBS PROVIDER NUMBER
MNNH0230OtherUCARE PROVIDER NUMBER
MN245572Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER