Provider Demographics
NPI:1811005846
Name:PARK PLACE NURSING AND REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:PARK PLACE NURSING AND REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:HISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-872-3471
Mailing Address - Street 1:100 PARK PL
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-7743
Mailing Address - Country:US
Mailing Address - Phone:334-872-3471
Mailing Address - Fax:334-872-8923
Practice Address - Street 1:100 PARK PL
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-7743
Practice Address - Country:US
Practice Address - Phone:334-872-3471
Practice Address - Fax:334-872-8923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12523314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4750840SMedicaid
AL6137410001Medicare NSC
AL015084Medicare Oscar/Certification