Basic Information
Provider Information | |||||||||
NPI: | 1285056994 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PINE MOUNTAIN NURSING HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PINE MOUNTAIN HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16233 ASKIN DR. | ||||||||
Address2: | SUITE A | ||||||||
City: | FRAZIER PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 932226536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612422592 | ||||||||
FaxNumber: | 6612627031 | ||||||||
Practice Location | |||||||||
Address1: | 770 10TH ST | ||||||||
Address2: |   | ||||||||
City: | ARCATA | ||||||||
State: | CA | ||||||||
PostalCode: | 955216210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7078268633 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2014 | ||||||||
LastUpdateDate: | 12/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POWELL | ||||||||
AuthorizedOfficialFirstName: | SHARON | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6612422592 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | FNP-C | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | C3624118 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.