MEDICARE: COLONIAL MANOR HEALTH CARE CENTER, INC.

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	314000000X	Skilled Nursing Facility	2482	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

General Provider Information

NPI Number	:	1386639078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLONIAL MANOR HEALTH CARE CENTER, INC.

Provider Business Mailing Address
First Line	:	747 S MOUNT VERNON AVE
Second Line	:
City	:	LOUDONVILLE
State	:	OH
Zip	:	44842-1416
Country	:	US
Telephone Number	:	419-994-4191
Fax Number	:

Provider Business Practice Location Address
First Line	:	747 S MOUNT VERNON AVE
Second Line	:
City	:	LOUDONVILLE
State	:	OH
Zip	:	44842-1416
Country	:	US
Telephone Number	:	419-994-4191
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MRS. LINDA SUE SNOWBARGER
Credential	:	NHA
Telephone Number	:	419-994-4191

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	05/10/2012

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