=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902310774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACP CARMICHAEL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2017
-----------------------------------------------------
Last Update Date | 11/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7125 FAIR OAKS BLVD
-----------------------------------------------------
City | CARMICHAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95608-6450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-481-7105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 E MAIN ST STE 404
-----------------------------------------------------
City | BOZEMAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59715-4787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-271-9635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | CHRIS ROSENSTOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-271-9635
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------