Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 S MOUNT VERNON AVE
LOUDONVILLE OH
44842-1416
US

IV. Provider business mailing address

747 S MOUNT VERNON AVE
LOUDONVILLE OH
44842-1416
US

V. Phone/Fax

Practice location:
  • Phone: 419-994-4191
  • Fax:
Mailing address:
  • Phone: 419-994-4191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2482
License Number StateOH

VIII. Authorized Official

Name: MRS. LINDA SUE SNOWBARGER
Title or Position: OWNER/ADMINISTRATOR
Credential: NHA
Phone: 419-994-4191