1255405205 NPI number — RULEVILLE NURSING AND REHABILIATION CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255405205 NPI number — RULEVILLE NURSING AND REHABILIATION CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RULEVILLE NURSING AND REHABILIATION CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255405205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORCHARD PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14127-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-662-4955
Provider Business Mailing Address Fax Number:
716-667-9230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 STANSEL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RULEVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38771-3320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-756-4361
Provider Business Practice Location Address Fax Number:
662-756-2788
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
NORBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CO-CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
716-662-4955

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  913 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 007031277 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000080393 . This is a "BC BS OF MISSISSIPPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 07031277 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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