Provider Demographics
NPI:1467406298
Name:COLLINSVILLE NURSING HOME, INC
Entity Type:Organization
Organization Name:COLLINSVILLE NURSING HOME, INC
Other - Org Name:COLLINSVILLE HEALTHCARE & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:COKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:256-524-2117
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35961-0310
Mailing Address - Country:US
Mailing Address - Phone:256-524-2117
Mailing Address - Fax:256-524-2035
Practice Address - Street 1:685 NORTH VALLEY AVE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35961
Practice Address - Country:US
Practice Address - Phone:256-524-2117
Practice Address - Fax:256-524-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12525314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4754120SMedicaid
AL4754120SMedicaid