=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619211646
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID E CHILDS JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2012
-----------------------------------------------------
Last Update Date | 11/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2350 CHERRY AVE
-----------------------------------------------------
City | ALLIANCE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44601-5022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-821-3939
-----------------------------------------------------
Fax | 330-829-9734
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 360 WABASH AVE N
-----------------------------------------------------
City | BREWSTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44613-1042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-767-3451
-----------------------------------------------------
Fax | 330-767-3452
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 3494
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------