Provider Demographics
NPI:1790782639
Name:NORTH SHORE MANOR, INC.
Entity Type:Organization
Organization Name:NORTH SHORE MANOR, INC.
Other - Org Name:NORTH SHORE HEALTH & REHAB FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:A/R MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEB
Authorized Official - Middle Name:
Authorized Official - Last Name:PRENTISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-482-0198
Mailing Address - Street 1:1365 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-2561
Mailing Address - Country:US
Mailing Address - Phone:970-677-6111
Mailing Address - Fax:970-667-2460
Practice Address - Street 1:1365 W 29TH ST
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-2561
Practice Address - Country:US
Practice Address - Phone:970-677-6111
Practice Address - Fax:970-667-2460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0214314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05651294Medicaid
COCD2203Medicare PIN
CO065129Medicare ID - Type UnspecifiedMEDICARE BILLING NUMBER