=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891060729
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNSET HARBOR ASSISTED LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2012
-----------------------------------------------------
Last Update Date | 03/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 522 DORIC CT
-----------------------------------------------------
City | TARPON SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34689-2526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-940-4781
-----------------------------------------------------
Fax | 888-688-1401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5901 US HIGHWAY 19 SUITE 7B
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-2960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-940-4781
-----------------------------------------------------
Fax | 888-688-1401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | ROLAND B RICHARDS
-----------------------------------------------------
Credential | ADMINISTRATOR
-----------------------------------------------------
Telephone | 727-940-4781
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12109
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------