Healthcare Provider Details

I. General information

NPI: 1659368124
Provider Name (Legal Business Name): SUNSHINE MANOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

894 LELAND AVE
UNIVERSITY CITY MO
63130-3239
US

IV. Provider business mailing address

894 LELAND AVE
UNIVERSITY CITY MO
63130-3239
US

V. Phone/Fax

Practice location:
  • Phone: 314-726-4767
  • Fax: 314-726-1308
Mailing address:
  • Phone: 314-726-4767
  • Fax: 314-726-1308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number037234
License Number StateMO

VIII. Authorized Official

Name: DR. SHARO SHIRSHEKAN
Title or Position: MANAGING MEMBER
Credential:
Phone: 573-701-0600