=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144644998
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINE MOUNTAIN NURSING HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2014
-----------------------------------------------------
Last Update Date | 02/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16233 ASKIN DR SUITE A
-----------------------------------------------------
City | FRAZIER PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93222-6536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-242-7220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16233 ASKIN DRIVE SUITE A
-----------------------------------------------------
City | PINE MOUNTAIN CLUB
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93222-6536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-242-7220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SHARON POWELL
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 661-242-7220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number | NP14217
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------