Provider Demographics
NPI:1770905721
Name:SUNSHINE SENIOR LIVING LLC
Entity type:Organization
Organization Name:SUNSHINE SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENDON
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:435-414-4646
Mailing Address - Street 1:2456 E 2150 SOUTH CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-6531
Mailing Address - Country:US
Mailing Address - Phone:435-414-4646
Mailing Address - Fax:
Practice Address - Street 1:2456 E 2150 SOUTH CIR
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6531
Practice Address - Country:US
Practice Address - Phone:435-414-4646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2014-AL1-UT000G2G310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility