Healthcare Provider Details

I. General information

NPI: 1689671158
Provider Name (Legal Business Name): SUNSET KNOLL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 WEST 5TH STREET
AURELIA IA
51005-0067
US

IV. Provider business mailing address

401 WEST 5TH STREET
AURELIA IA
51005-0067
US

V. Phone/Fax

Practice location:
  • Phone: 712-434-2294
  • Fax: 712-434-2153
Mailing address:
  • Phone: 712-434-2294
  • Fax: 712-434-2153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number165535
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number180325
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0803940
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: DAVID R JOHNSON
Title or Position: PRESIDENT
Credential:
Phone: 712-434-2294