=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669422853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHORE LIFECARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 01/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26181 PARKSLEY RD
-----------------------------------------------------
City | PARKSLEY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23421-3723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-665-5133
-----------------------------------------------------
Fax | 757-665-5136
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 608 DENBIGH BLVD STE 600
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23608-4411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-875-2023
-----------------------------------------------------
Fax | 757-875-2016
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR VP/CFO/TREASURER
-----------------------------------------------------
Name | WALTER WILLIAM AUSTIN JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-531-7015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | NH2475
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------