Basic Information
| Provider Information | |||||||||
| NPI: | 1104254218 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BERTRAND NURSING & REHAB CTR LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BERTRAND NURSING AND REHAB CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 603 HIGHWAY 62 W | ||||||||
| Address2: | |||||||||
| City: | BERTRAND | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638239738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736834290 | ||||||||
| FaxNumber: | 5736834304 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 HIGHWAY 62 W | ||||||||
| Address2: | |||||||||
| City: | BERTRAND | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638239738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732334464 | ||||||||
| FaxNumber: | 5734721880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2013 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHANCE | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5736834290 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 041755 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 101480002 | 05 | MO | MEDICAID |