Provider Demographics
NPI:1205049160
Name:OMNI MANOR, INC.
Entity type:Organization
Organization Name:OMNI MANOR, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MADELINE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:D'AGOSTINO
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:330-793-4404
Mailing Address - Street 1:3259 VESTAL RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-1062
Mailing Address - Country:US
Mailing Address - Phone:330-793-4404
Mailing Address - Fax:330-793-0630
Practice Address - Street 1:3259 VESTAL RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-1062
Practice Address - Country:US
Practice Address - Phone:330-793-4404
Practice Address - Fax:330-793-0630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2022R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH150284487Medicaid