MEDICARE: SUNNY RIDGE RETIREMENT AND ALF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	AL# 11175	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073956827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNNY RIDGE RETIREMENT AND ALF

Provider Business Mailing Address
First Line	:	1713 W EUCLID AVE
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-2930
Country	:	US
Telephone Number	:	386-490-4940
Fax Number	:

Provider Business Practice Location Address
First Line	:	1713 W EUCLID AVE
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-2930
Country	:	US
Telephone Number	:	386-490-4940
Fax Number	:

Authorized Official
Title or Position	:	ASST.ADMINISTRATOR
Name	:	MARILOU R OCAMPO
Credential	:
Telephone Number	:	386-490-4940

Provider Enumeration Date	:	04/11/2013
Last Update Date	:	04/11/2013

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