=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053563536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHIRLEY'S ICF DD N NO 5
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2008
-----------------------------------------------------
Last Update Date | 10/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9565 COLINGTON PL
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95209-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-952-6027
-----------------------------------------------------
Fax | 209-952-7829
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1182 DUVALL CT
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95210-3581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-475-9829
-----------------------------------------------------
Fax | 209-475-9845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MRS. SHIRLEY E GAPASIN
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 209-607-9380
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 5500000686
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------