=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609916519
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIMES CONVALESCENT CENTER, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 02/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 KIMES LN
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45701-3801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-593-3391
-----------------------------------------------------
Fax | 740-594-1632
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 KIMES LN
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45701-3801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-593-3391
-----------------------------------------------------
Fax | 740-594-1632
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | LAURA BUCKLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 740-593-3391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 1226N
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------