=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063807113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNDANCE LIFE ENRICHMENT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2015
-----------------------------------------------------
Last Update Date | 04/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3875 TAYLOR RD STE 204G
-----------------------------------------------------
City | LOOMIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95650-9273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-401-2078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1525
-----------------------------------------------------
City | LOOMIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95650-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHEA PHINNEY RIDLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-401-2078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 50023
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------