=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407191588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESCOTT NURSING AND REHABILITATION CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2012
-----------------------------------------------------
Last Update Date | 01/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 864 DOUGHERTY ST
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86305-1841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-778-9667
-----------------------------------------------------
Fax | 520-393-1044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 N LA CANADA DR
-----------------------------------------------------
City | GREEN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85614-3129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-352-3018
-----------------------------------------------------
Fax | 520-393-1044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VICE PRESIDENT
-----------------------------------------------------
Name | CARL ZIMMERMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-352-3019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NCI-379
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------