1740319664 NPI number — PORTLAND NURSING & REHAB CENTER, INC.

Table of content: (NPI 1740319664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740319664 NPI number — PORTLAND NURSING & REHAB CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTLAND NURSING & REHAB CENTER, INC.
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:
HIGHLAND MANOR NURSING & REHAB CENTER
Provider Other Organization Name Type Code:
3
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:
1740319664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
602 COURTLAND ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32804-1360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-975-3000
Provider Business Mailing Address Fax Number:
407-975-3090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 HIGHLAND CIRCLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37148-4918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-325-9263
Provider Business Practice Location Address Fax Number:
615-325-5776
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RODMAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
ASST. SECRETARY
Authorized Official Telephone Number:
407-975-3011

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0000000270 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 744-0308 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1454187 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 044-5306 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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