=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265432777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LINGENFELTER CENTER, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2005
-----------------------------------------------------
Last Update Date | 07/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1099 SUNRISE AVE
-----------------------------------------------------
City | KINGMAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-718-4852
-----------------------------------------------------
Fax | 928-718-4856
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1099 SUNRISE AVE
-----------------------------------------------------
City | KINGMAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86401-6825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-718-4852
-----------------------------------------------------
Fax | 928-718-4856
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | AMY ELSBURY
-----------------------------------------------------
Credential | RN, BSN, MA
-----------------------------------------------------
Telephone | 928-718-4852
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NCI 2635
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------