=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609223098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FSH FISHER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2016
-----------------------------------------------------
Last Update Date | 05/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22371 BANDUCCI RD
-----------------------------------------------------
City | TEHACHAPI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93561-7720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-822-6457
-----------------------------------------------------
Fax | 661-822-6458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22371 BANDUCCI RD
-----------------------------------------------------
City | TEHACHAPI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93561-7720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-822-6457
-----------------------------------------------------
Fax | 661-822-6458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MRS. DARLENE FAYE FERGUSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 661-330-6501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 155801217
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------