Provider Demographics
NPI:1902305840
Name:ASHLEY MANOR, LLC
Entity Type:Organization
Organization Name:ASHLEY MANOR, LLC
Other - Org Name:ASHLEY MANOR EVANS I
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED PERSON
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:120-891-4313
Mailing Address - Street 1:PO BOX 1176
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83680-1176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1805 32ND ST
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-3422
Practice Address - Country:US
Practice Address - Phone:208-376-7298
Practice Address - Fax:208-376-7298
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASHLEY MANOR, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-06
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility