=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013941764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONROE MANOR NURSING HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 03/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 236 W CLAIBORNE ST
-----------------------------------------------------
City | MONROEVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36460-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-575-2648
-----------------------------------------------------
Fax | 251-575-2647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 SOUTHERN WAY
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36619-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-433-9801
-----------------------------------------------------
Fax | 251-433-9807
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. ZED D PERRIGIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 251-575-2648
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 12646
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------