MEDICARE: COLONIAL MANOR LTC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	3620	OH
2	314000000X	Skilled Nursing Facility	3620	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164411187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLONIAL MANOR LTC, LLC

Provider Business Mailing Address
First Line	:	1528 MARKET AVE N
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44714-2695
Country	:	US
Telephone Number	:	330-453-8466
Fax Number	:	330-453-1424

Provider Business Practice Location Address
First Line	:	1528 MARKET AVE N
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44714-2695
Country	:	US
Telephone Number	:	330-453-8466
Fax Number	:	330-453-1424

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL P SLYK
Credential	:	PHARMD FASCP
Telephone Number	:	330-424-3721

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	09/11/2025

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Directions to “COLONIAL MANOR LTC, LLC ” Practice Location

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