Provider Demographics
NPI:1740319664
Name:PORTLAND NURSING & REHAB CENTER, INC.
Entity type:Organization
Organization Name:PORTLAND NURSING & REHAB CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASST. SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-975-3011
Mailing Address - Street 1:602 COURTLAND ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-1360
Mailing Address - Country:US
Mailing Address - Phone:407-975-3000
Mailing Address - Fax:407-975-3090
Practice Address - Street 1:215 HIGHLAND CIRCLE DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-4918
Practice Address - Country:US
Practice Address - Phone:615-325-9263
Practice Address - Fax:615-325-5776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000270314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN744-0308Medicaid
TN1454187Medicaid
TN044-5306Medicaid
TN1454187Medicaid
TN744-0308Medicaid