=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306907324
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIENNA ENTERPRISES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 EAST NATIONAL ROAD
-----------------------------------------------------
City | SOUTH VIENNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45369-0447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-568-4342
-----------------------------------------------------
Fax | 937-568-4265
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 EAST NATIONAL ROAD
-----------------------------------------------------
City | S. VIENNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45369-0447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-568-4342
-----------------------------------------------------
Fax | 937-568-4265
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. MARK ROBERT WARNER
-----------------------------------------------------
Credential | NHA
-----------------------------------------------------
Telephone | 937-568-4342
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 613
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------