Healthcare Provider Details

I. General information

NPI: 1457695165
Provider Name (Legal Business Name): SUN LAKES THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21094 LAWRENCE 2072
ASH GROVE MO
65604
US

IV. Provider business mailing address

21094 LAWRENCE 2072
ASH GROVE MO
65604
US

V. Phone/Fax

Practice location:
  • Phone: 417-773-6388
  • Fax:
Mailing address:
  • Phone: 417-773-6388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2001001805
License Number StateMO

VIII. Authorized Official

Name: MS. KRISTI JAN HAYNES
Title or Position: OCCUPATIONAL THERAPY ASSISTANT
Credential: COTA/L
Phone: 417-773-6388