=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720338239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PORTERVILLE SHELTERED WORKSHOP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2012
-----------------------------------------------------
Last Update Date | 09/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1924 S NEWCOMB ST
-----------------------------------------------------
City | PORTERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93257-8923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-781-0352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 187 W OLIVE AVE
-----------------------------------------------------
City | PORTERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93257-3449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. JOHN U. NASH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 559-784-1399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------