Provider Demographics
NPI:1730243932
Name:MOTHER ANGELINE MCCRORY MANOR, INC.
Entity type:Organization
Organization Name:MOTHER ANGELINE MCCRORY MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-751-5700
Mailing Address - Street 1:5199 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-3800
Mailing Address - Country:US
Mailing Address - Phone:614-751-5700
Mailing Address - Fax:614-751-8311
Practice Address - Street 1:5199 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-3800
Practice Address - Country:US
Practice Address - Phone:614-751-5700
Practice Address - Fax:614-751-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2422N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2542636Medicaid
OH2542636Medicaid