Healthcare Provider Details

I. General information

NPI: 1790451839
Provider Name (Legal Business Name): SUNSHINE THERAPEUTIC GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4907 HIGHWAY 84 W
VIDALIA LA
71373-3579
US

IV. Provider business mailing address

4907 HIGHWAY 84 W
VIDALIA LA
71373-3579
US

V. Phone/Fax

Practice location:
  • Phone: 601-807-3833
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: TINA BRUCE
Title or Position: OWNER
Credential: LPC
Phone: 601-807-3833