Provider Demographics
NPI:1790780153
Name:COLONIAL MANOR OPERATING CO., INC.
Entity Type:Organization
Organization Name:COLONIAL MANOR OPERATING CO., INC.
Other - Org Name:CAMPUS HEALTH 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:D
Authorized Official - Last Name:NORDQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-726-6047
Mailing Address - Street 1:196 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-2139
Mailing Address - Country:US
Mailing Address - Phone:330-759-8000
Mailing Address - Fax:330-759-4540
Practice Address - Street 1:196 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-2139
Practice Address - Country:US
Practice Address - Phone:330-759-8000
Practice Address - Fax:330-759-4540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1544N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1544NOtherNURSING HOME LICENSE #
OH2488080Medicaid
OH1544NOtherNURSING HOME LICENSE #