Provider Demographics
NPI:1124066923
Name:ROBERTSDALE NURSING HOME INC
Entity type:Organization
Organization Name:ROBERTSDALE NURSING HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:POLYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-947-1911
Mailing Address - Street 1:1 SOUTHERN WAY
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36619-1210
Mailing Address - Country:US
Mailing Address - Phone:251-433-9801
Mailing Address - Fax:251-433-9807
Practice Address - Street 1:18700 US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:ROBERTSDALE
Practice Address - State:AL
Practice Address - Zip Code:36567-3271
Practice Address - Country:US
Practice Address - Phone:251-947-1911
Practice Address - Fax:251-947-1937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12479314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL475807OSMedicaid
AL015443Medicare Oscar/Certification
AL6096710001Medicare NSC