Provider Demographics
NPI:1215344288
Name:MCKENNA HEALTHCARE OF PORTSMOUTH, INC.
Entity type:Organization
Organization Name:MCKENNA HEALTHCARE OF PORTSMOUTH, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:BERGSTEN
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:937-825-6622
Mailing Address - Street 1:1319 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3715
Mailing Address - Country:US
Mailing Address - Phone:740-354-6619
Mailing Address - Fax:740-354-5710
Practice Address - Street 1:1319 SPRING ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3715
Practice Address - Country:US
Practice Address - Phone:740-354-6619
Practice Address - Fax:740-354-5710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-22
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH365867Medicare Oscar/Certification