Basic Information
| Provider Information | |||||||||
| NPI: | 1225024664 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | N & R OF BERTRAND, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BERTRAND RETIREMENT HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 603 HIGHWAY 62 W | ||||||||
| Address2: | |||||||||
| City: | BERTRAND | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638239738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736834290 | ||||||||
| FaxNumber: | 5734716161 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 HIGHWAY 62 W | ||||||||
| Address2: | |||||||||
| City: | BERTRAND | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638239738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736834290 | ||||||||
| FaxNumber: | 5734716161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 11/04/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LINCOLN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SHAREHOLDER | ||||||||
| AuthorizedOfficialTelephone: | 5737467100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 030478 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 16878035 | 01 | MO | STATE ID | OTHER | 101480002 | 05 | MO | MEDICAID |