=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235134446
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARBON COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2005
-----------------------------------------------------
Last Update Date | 10/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 EVERGREEN AVE
-----------------------------------------------------
City | WEATHERLY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18255-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-427-8683
-----------------------------------------------------
Fax | 570-427-4988
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 EVERGREEN AVE
-----------------------------------------------------
City | WEATHERLY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18255-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-427-8683
-----------------------------------------------------
Fax | 570-427-4988
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSING HOME ADMINISTRATOR
-----------------------------------------------------
Name | MRS. LOUISE BEKISZ
-----------------------------------------------------
Credential | NHA
-----------------------------------------------------
Telephone | 570-427-8683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 030602
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------