Healthcare Provider Details

I. General information

NPI: 1336575752
Provider Name (Legal Business Name): PORTAGEVILLE NURSING AND REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 W STATE HIGHWAY 162
PORTAGEVILLE MO
63873-9397
US

IV. Provider business mailing address

401 N ELM ST
DENTON TX
76201-4137
US

V. Phone/Fax

Practice location:
  • Phone: 573-379-2017
  • Fax: 573-379-2753
Mailing address:
  • Phone: 573-379-2017
  • Fax: 573-379-2753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL A RICH
Title or Position: PRESIDENT
Credential:
Phone: 940-387-4388