Basic Information
| Provider Information | |||||||||
| NPI: | 1568762854 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LP PORTLAND, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SIGNATURE HEALTHCARE OF PORTLAND REHAB & WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12201 BLUEGRASS PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402992361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025687800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 215 HIGHLAND CIRCLE DR | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371484918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153259263 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2010 | ||||||||
| LastUpdateDate: | 04/05/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRISON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5025687800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SIGNATURE HEALTHCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 270 | TN | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 270 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.