Basic Information
| Provider Information | |||||||||
| NPI: | 1033200068 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLEASANT GROVE NURSING AND REHABILITATION CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PLEASANT GROVE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351271962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057448226 | ||||||||
| FaxNumber: | 2057448211 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PLEASANT GROVE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351271962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057448226 | ||||||||
| FaxNumber: | 2057448211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | NORBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-CEO | ||||||||
| AuthorizedOfficialTelephone: | 7166624955 | ||||||||
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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 | 12574 | AL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4757310S | 05 | AL | MEDICAID | 00385 | 01 | AL | BC BS OF ALAMBAMA | OTHER | 71-00024 | 01 | AL | MEDICARE COMPLETE | OTHER |