Provider Demographics
NPI:1487640777
Name:N & R OF PORTAGEVILLE, INC.
Entity Type:Organization
Organization Name:N & R OF PORTAGEVILLE, INC.
Other - Org Name:PORTAGEVILLE NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSPETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-392-0316
Mailing Address - Street 1:PO BOX 408
Mailing Address - Street 2:
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873-0408
Mailing Address - Country:US
Mailing Address - Phone:573-379-2017
Mailing Address - Fax:573-379-2735
Practice Address - Street 1:290 W STATE HIGHWAY 162
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-9397
Practice Address - Country:US
Practice Address - Phone:573-379-2017
Practice Address - Fax:573-379-2735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030678314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO16877926OtherSTATE ID
MO103235008Medicaid
MO16877926OtherSTATE ID