Basic Information
| Provider Information | |||||||||
| NPI: | 1194970343 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BENCHMARK HEALTHCARE OF PORTAGEVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17826 EDISON AVE | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630051262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365365365 | ||||||||
| FaxNumber: | 6365364533 | ||||||||
| Practice Location | |||||||||
| Address1: | 290 W STATE HIGHWAY 162 | ||||||||
| Address2: | |||||||||
| City: | PORTAGEVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638739397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733792017 | ||||||||
| FaxNumber: | 5733792735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 01/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | SELLS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6365365365 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 035353 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.