1801889811 NPI number — COLONIAL MANORS OF FAYETTE, INC

Table of content: (NPI 1801889811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801889811 NPI number — COLONIAL MANORS OF FAYETTE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONIAL MANORS OF FAYETTE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801889811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 BOLGER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52142-9762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-425-3336
Provider Business Mailing Address Fax Number:
563-425-3512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 BOLGER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52142-9762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-425-3336
Provider Business Practice Location Address Fax Number:
563-425-3512
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HELDT
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
NURSING HOME ADMINISTRATOR
Authorized Official Telephone Number:
563-425-3336

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  S0204 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 330221 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0802470 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com