=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750784906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENNYROYAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2014
-----------------------------------------------------
Last Update Date | 10/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 TAN OAK AVE
-----------------------------------------------------
City | CAMP MEEKER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-812-6683
-----------------------------------------------------
Fax | 707-294-6289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 131
-----------------------------------------------------
City | CAMP MEEKER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95419-0131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-812-6683
-----------------------------------------------------
Fax | 707-294-6289
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHEIF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MRS. IVY ROSE HUNTER
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 707-812-6683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------