Healthcare Provider Details

I. General information

NPI: 1790780153
Provider Name (Legal Business Name): COLONIAL MANOR OPERATING CO., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 COLONIAL DR
YOUNGSTOWN OH
44505-2139
US

IV. Provider business mailing address

196 COLONIAL DR
YOUNGSTOWN OH
44505-2139
US

V. Phone/Fax

Practice location:
  • Phone: 330-759-8000
  • Fax: 330-759-4540
Mailing address:
  • Phone: 330-759-8000
  • Fax: 330-759-4540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1544N
License Number StateOH

VIII. Authorized Official

Name: MR. THOMAS D. NORDQUIST
Title or Position: PRESIDENT
Credential:
Phone: 330-726-6047