=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982691366
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC HEALTHCARE & REHABILITATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2005
-----------------------------------------------------
Last Update Date | 04/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2211 HARRISON AVE
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-3214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-443-9767
-----------------------------------------------------
Fax | 707-441-8447
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2211 HARRISON AVE
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-3214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-443-9767
-----------------------------------------------------
Fax | 707-441-8447
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. ALICE L O'NEILL
-----------------------------------------------------
Credential | MS,RD, NHS
-----------------------------------------------------
Telephone | 707-443-9767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 010000051
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------