=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316976491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLONIAL MANORS OF OAKLAND, IOWA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2006
-----------------------------------------------------
Last Update Date | 12/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 737 NORTH HIWAY
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51560-0459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-482-6403
-----------------------------------------------------
Fax | 712-482-6879
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 459
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51560-0459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-482-6403
-----------------------------------------------------
Fax | 712-482-6879
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. CHARLES ALAN PLEAK
-----------------------------------------------------
Credential | CNHA
-----------------------------------------------------
Telephone | 712-482-6403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 780147
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------