=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205193901
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTHEA REHABILITATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2012
-----------------------------------------------------
Last Update Date | 04/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3397 S CAROL DR
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-9010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-853-5906
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3397 S CAROL DR
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-9010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-853-5906
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REHAB MANAGER
-----------------------------------------------------
Name | DAN LOERA
-----------------------------------------------------
Credential | OCCUPATIONAL THERAIS
-----------------------------------------------------
Telephone | 928-853-5906
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 3329
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------