Healthcare Provider Details

I. General information

NPI: 1457280281
Provider Name (Legal Business Name): SUPPORTIVE INDEPENDENT SHARED HOUSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 GRAND AVE STE 100
DES MOINES IA
50312-5381
US

IV. Provider business mailing address

2323 GRAND AVE STE 100
DES MOINES IA
50312-5381
US

V. Phone/Fax

Practice location:
  • Phone: 515-218-8851
  • Fax:
Mailing address:
  • Phone: 515-218-8851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: RAENESHA LUNA
Title or Position: CEO
Credential:
Phone: 515-218-8851