=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417783580
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESCOTT VALLEY NURSING & REHABILITATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2024
-----------------------------------------------------
Last Update Date | 09/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3380 N WINDSONG DR
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86314-2262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-775-0045
-----------------------------------------------------
Fax | 928-775-2752
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3380 N WINDSONG DR
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86314-2262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-775-0045
-----------------------------------------------------
Fax | 928-775-2752
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | DAVID GARETZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-987-5954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------