=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467403782
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GGNSC SHIPPENVILLE LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2006
-----------------------------------------------------
Last Update Date | 07/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21158 PAINT BLVD
-----------------------------------------------------
City | SHIPPENVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16254-4024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-226-5660
-----------------------------------------------------
Fax | 814-226-9896
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21158 PAINT BLVD
-----------------------------------------------------
City | SHIPPENVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16254-4024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-226-5660
-----------------------------------------------------
Fax | 814-226-9896
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SEC. OF THE GP
-----------------------------------------------------
Name | HOLLY A. RASMUSSEN-JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-201-4835
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 026002
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------