=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992809156
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HCM QUINCY CONVALESCENT HOSP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2006
-----------------------------------------------------
Last Update Date | 08/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 CENTRAL AVENUE
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95971-9718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-283-2110
-----------------------------------------------------
Fax | 530-283-2110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 CENTRAL AVENUE
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95971-9718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-283-2110
-----------------------------------------------------
Fax | 530-283-2274
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE ACCOUNTING MANAGER
-----------------------------------------------------
Name | HOLLEE A NYBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 559-707-8737
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------