Basic Information
| Provider Information | |||||||||
| NPI: | 1811005846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARK PLACE NURSING AND REHABILITATION CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARK PL | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367017743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348723471 | ||||||||
| FaxNumber: | 3348728923 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PARK PL | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367017743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348723471 | ||||||||
| FaxNumber: | 3348728923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 02/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | HISE | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3348723471 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 12523 | AL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4750840S | 05 | AL | MEDICAID |