Provider Demographics
NPI:1669450615
Name:PLYMOUTH MANOR INC
Entity Type:Organization
Organization Name:PLYMOUTH MANOR INC
Other - Org Name:PLYMOUTH MANOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:AMLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-290-1490
Mailing Address - Street 1:954 7TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-2602
Mailing Address - Country:US
Mailing Address - Phone:712-546-7831
Mailing Address - Fax:712-546-7990
Practice Address - Street 1:954 7TH AVE SE
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2602
Practice Address - Country:US
Practice Address - Phone:712-546-7831
Practice Address - Fax:712-546-7990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA750234314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0803288Medicaid
IA165311Medicare Oscar/Certification