Provider Demographics
NPI:1609027549
Name:COLONIAL MANOR OF ELMA
Entity Type:Organization
Organization Name:COLONIAL MANOR OF ELMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-456-5636
Mailing Address - Street 1:1320 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:IA
Mailing Address - Zip Code:50441-1104
Mailing Address - Country:US
Mailing Address - Phone:641-456-5636
Mailing Address - Fax:641-456-2320
Practice Address - Street 1:407 9TH ST
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:IA
Practice Address - Zip Code:50628-8217
Practice Address - Country:US
Practice Address - Phone:641-393-2125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0653865Medicaid