Healthcare Provider Details

I. General information

NPI: 1952878936
Provider Name (Legal Business Name): SUSH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 E RIVERSIDE DR STE A102
ST GEORGE UT
84790-8692
US

IV. Provider business mailing address

2019 E RIVERSIDE DR STE A102
ST GEORGE UT
84790-8692
US

V. Phone/Fax

Practice location:
  • Phone: 435-627-2155
  • Fax:
Mailing address:
  • Phone: 435-668-0173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: TAYSIA KAI RANDALL
Title or Position: DIRECTOR/OWNER
Credential:
Phone: 435-668-0173