=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720281942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNRISE HOME FACILITY I
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11002 NORTH 66TH STREET
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-367-9117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11002 NORTH 66TH STREET
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-367-9117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | LIDA CUBILLOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-367-9117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | ALH5605
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------