=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992794788
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW GLASGOW HEALTH & REHABILITATION CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2005
-----------------------------------------------------
Last Update Date | 09/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 WESTWOOD ST
-----------------------------------------------------
City | GLASGOW
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42141-1028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-651-6661
-----------------------------------------------------
Fax | 270-651-7881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 938
-----------------------------------------------------
City | GLASGOW
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42142-0938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-651-6661
-----------------------------------------------------
Fax | 270-651-7881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. THOMAS JASON GUMM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-651-6661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 100014
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------