1508828120 NPI number — SUNNY KNOLL CARE CENTER, LLC

Table of content: (NPI 1508828120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508828120 NPI number — SUNNY KNOLL CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNNY KNOLL CARE CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SUNNY KNOLL CARE CENTER, LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508828120
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5115 E STATE ROAD 64
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34208-5509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-758-4745
Provider Business Mailing Address Fax Number:
941-751-2135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 WARNER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKWELL CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50579-1722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-297-8918
Provider Business Practice Location Address Fax Number:
712-297-5535
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENCH
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
AUTHORIZED REPRESENTATIVE
Authorized Official Telephone Number:
941-758-4745

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  130168 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0803858 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0800076 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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