=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255609467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOLID ROCK ADULT DAY CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2011
-----------------------------------------------------
Last Update Date | 12/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10911 MARKET AVE NW
-----------------------------------------------------
City | UNIONTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44685-7669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-990-1777
-----------------------------------------------------
Fax | 330-877-1996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10911 MARKET AVE NW
-----------------------------------------------------
City | UNIONTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44685-7669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 330-877-1996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. NADINE LYNN VONGUNTEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-990-1777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 2043830
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------