Basic Information
| Provider Information | |||||||||
| NPI: | 1255320032 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLONIAL MANOR NURSING CENTER-CLEBURNE, L.P. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLONIAL MANOR NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 DRYDEN ROAD | ||||||||
| Address2: | SUITE 2000 | ||||||||
| City: | DRESHER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190251048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154417700 | ||||||||
| FaxNumber: | 2154414255 | ||||||||
| Practice Location | |||||||||
| Address1: | 2035 N. GRANBURY STREET | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760337460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176459134 | ||||||||
| FaxNumber: | 8176414662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 10/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | LICARI | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2154417700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BN1400X | 115703 | TX | N | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 332BP3500X | 115703 | TX | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 314000000X | 108467 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004525 | 05 | TX | MEDICAID |