Basic Information
| Provider Information | |||||||||
| NPI: | 1740319664 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTLAND NURSING & REHAB CENTER, INC. | ||||||||
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| OtherOrganizationName: | HIGHLAND MANOR NURSING & REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 COURTLAND ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328041360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079753000 | ||||||||
| FaxNumber: | 4079753090 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 HIGHLAND CIRCLE DR | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371484918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153259263 | ||||||||
| FaxNumber: | 6153255776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 04/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | RODMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASST. SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4079753011 | ||||||||
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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 | 0000000270 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 744-0308 | 05 | TN | MEDICAID | 1454187 | 05 | TN | MEDICAID | 044-5306 | 05 | TN | MEDICAID |