Provider Demographics
NPI:1922786615
Name:CHILLICOTHE MANOR I LLC
Entity Type:Organization
Organization Name:CHILLICOTHE MANOR I LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EDERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-708-3503
Mailing Address - Street 1:445 CENTRAL AVE UNIT 215
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-2021
Mailing Address - Country:US
Mailing Address - Phone:516-708-3503
Mailing Address - Fax:
Practice Address - Street 1:1301 MONROE ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-1345
Practice Address - Country:US
Practice Address - Phone:660-646-5180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility