Provider Demographics
NPI:1336575752
Name:PORTAGEVILLE NURSING AND REHABILITATION, LLC
Entity Type:Organization
Organization Name:PORTAGEVILLE NURSING AND REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-387-4388
Mailing Address - Street 1:401 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-4137
Mailing Address - Country:US
Mailing Address - Phone:573-379-2017
Mailing Address - Fax:573-379-2753
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:573-379-2753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
265549Medicare Oscar/Certification