=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689627424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGHLANDS NURSING AND REHABILITATION CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 07/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 STEVENS AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40205-1044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-451-7330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 STEVENS AVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40205-1044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-451-7330
-----------------------------------------------------
Fax | 502-238-5240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MARIA ELVA GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-385-4364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 100218
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------