=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063177350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUN AND SEA ASSISTED LIVING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2021
-----------------------------------------------------
Last Update Date | 11/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 740 7TH ST
-----------------------------------------------------
City | IMPERIAL BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91932-2106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-212-4716
-----------------------------------------------------
Fax | 858-756-2885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 740 7TH ST
-----------------------------------------------------
City | IMPERIAL BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91932-2106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-212-4716
-----------------------------------------------------
Fax | 858-756-2885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANNE OWENS-STONE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-775-1215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251T00000X
-----------------------------------------------------
Taxonomy Name | PACE Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------