Provider Demographics
NPI:1720270887
Name:ST. ANTHONY HEALTHCARE AND REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:ST. ANTHONY HEALTHCARE AND REHABILITATION CENTER, LLC
Other - Org Name:ST. ANTHONY HEALTHCARE AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:1400 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4153
Mailing Address - Country:US
Mailing Address - Phone:575-762-4705
Mailing Address - Fax:575-762-4199
Practice Address - Street 1:1400 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4153
Practice Address - Country:US
Practice Address - Phone:575-762-4705
Practice Address - Fax:575-762-4199
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-13
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1072314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
325076Medicare Oscar/Certification