=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255720942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLONY SHINY SERENITY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2015
-----------------------------------------------------
Last Update Date | 01/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3799 N PINE ISLAND RD
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33351-6528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-748-0809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3799 N PINE ISLAND RD
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33351-6528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-748-0809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL OFFICER
-----------------------------------------------------
Name | LONNIE STECKLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-748-0509
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 7250
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------