Healthcare Provider Details

I. General information

NPI: 1770456089
Provider Name (Legal Business Name): SUNSHINE SUPPORTIVE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3207 67TH AVE N
BROOKLYN CENTER MN
55429-1823
US

IV. Provider business mailing address

17119 72ND AVE N
MAPLE GROVE MN
55311-4565
US

V. Phone/Fax

Practice location:
  • Phone: 612-590-0154
  • Fax:
Mailing address:
  • Phone: 612-590-0154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: ELIJAH GEORGE NYAMBANE
Title or Position: DIRECTO
Credential:
Phone: 612-590-0154