Healthcare Provider Details

I. General information

NPI: 1124066923
Provider Name (Legal Business Name): ROBERTSDALE NURSING HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18700 US HIGHWAY 90
ROBERTSDALE AL
36567-3271
US

IV. Provider business mailing address

1 SOUTHERN WAY
MOBILE AL
36619-1210
US

V. Phone/Fax

Practice location:
  • Phone: 251-947-1911
  • Fax: 251-947-1937
Mailing address:
  • Phone: 251-433-9801
  • Fax: 251-433-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number12479
License Number StateAL

VIII. Authorized Official

Name: MRS. MARY KAY POLYS
Title or Position: ADMINISTRATOR
Credential:
Phone: 251-947-1911