=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639554488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNSHINE VILLA HOMES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2015
-----------------------------------------------------
Last Update Date | 07/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2520 JAMES ST
-----------------------------------------------------
City | SCOTT CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63780-1219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-264-2424
-----------------------------------------------------
Fax | 573-471-4918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 E MALONE AVE
-----------------------------------------------------
City | SIKESTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63801-3413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-471-0466
-----------------------------------------------------
Fax | 573-471-4918
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TERRY R COLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-380-4113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------