Provider Demographics
NPI:1760495717
Name:MEDICAL FACILITIES OF AMERICA XIX
Entity Type:Organization
Organization Name:MEDICAL FACILITIES OF AMERICA XIX
Other - Org Name:PULASKI HEALTH & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO, MFA INC. GENERAL PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAUDE
Authorized Official - Middle Name:NOVEL
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:540-776-7526
Mailing Address - Street 1:2917 PENN FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-4374
Mailing Address - Country:US
Mailing Address - Phone:540-989-3618
Mailing Address - Fax:540-774-9443
Practice Address - Street 1:2401 LEE HWY N
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301-2325
Practice Address - Country:US
Practice Address - Phone:540-980-3111
Practice Address - Fax:540-980-2502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2657314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4952944Medicaid
495294Medicare Oscar/Certification