Healthcare Provider Details

I. General information

NPI: 1538264015
Provider Name (Legal Business Name): COLUMBIA MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 E NIFONG BLVD
COLUMBIA MO
65201-3874
US

IV. Provider business mailing address

2012 E NIFONG BLVD
COLUMBIA MO
65201-3874
US

V. Phone/Fax

Practice location:
  • Phone: 573-449-1246
  • Fax: 573-874-8753
Mailing address:
  • Phone: 573-449-1246
  • Fax: 573-874-8753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number015988
License Number StateMO

VIII. Authorized Official

Name: BENJAMIN C. SCHEULEN
Title or Position: CEO
Credential:
Phone: 573-556-6240