=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780945154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAMOND D INN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2012
-----------------------------------------------------
Last Update Date | 06/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 234 W MAIN ST
-----------------------------------------------------
City | DELTA
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84624-9256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-864-2041
-----------------------------------------------------
Fax | 435-864-2042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 234 W MAIN ST
-----------------------------------------------------
City | DELTA
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84624-9256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-864-2041
-----------------------------------------------------
Fax | 435-864-2042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. JANE ANN DRAPER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 435-864-4424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 2011-ALI-14508
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------