=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447286356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRAIRIE LIVING CENTER, L.P.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2006
-----------------------------------------------------
Last Update Date | 09/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 MESA DRIVE
-----------------------------------------------------
City | PLAINVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-293-4855
-----------------------------------------------------
Fax | 806-293-2804
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 DRYDEN ROAD SUITE 2000
-----------------------------------------------------
City | DRESHER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19025-1048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-441-7700
-----------------------------------------------------
Fax | 215-441-4255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OF GENERAL PARTNER
-----------------------------------------------------
Name | MR. PETER J LICARI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-441-7700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BN1400X
-----------------------------------------------------
Taxonomy Name | Nursing Facility Supplies (DME)
-----------------------------------------------------
License Number | 118925
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BP3500X
-----------------------------------------------------
Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
-----------------------------------------------------
License Number | 118925
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 115199
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------