Provider Demographics
NPI:1033200068
Name:PLEASANT GROVE NURSING AND REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:PLEASANT GROVE NURSING AND REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NORBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-662-4955
Mailing Address - Street 1:30 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:AL
Mailing Address - Zip Code:35127-1962
Mailing Address - Country:US
Mailing Address - Phone:205-744-8226
Mailing Address - Fax:205-744-8211
Practice Address - Street 1:30 7TH ST
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:AL
Practice Address - Zip Code:35127-1962
Practice Address - Country:US
Practice Address - Phone:205-744-8226
Practice Address - Fax:205-744-8211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12574314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4757310SMedicaid
AL00385OtherBC BS OF ALAMBAMA
AL71-00024OtherMEDICARE COMPLETE
AL4757310SMedicaid