=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780001255
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNSET SENIOR SOCIAL CLUB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2014
-----------------------------------------------------
Last Update Date | 10/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9644 SW 72ND ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-3250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-595-5250
-----------------------------------------------------
Fax | 305-595-5251
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9644 SW 72ND ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-3250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-595-5250
-----------------------------------------------------
Fax | 305-595-5251
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. NAYS MANDILEGO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-595-5250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 9237
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------