MEDICARE: SCOTT CITY SUNSHINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1598371593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTT CITY SUNSHINE LLC

Provider Business Mailing Address
First Line	:	37 DOCTORS PARK STE 3
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63703-4903
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2520 JAMES ST
Second Line	:
City	:	SCOTT CITY
State	:	MO
Zip	:	63780-1219
Country	:	US
Telephone Number	:	573-264-2424
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KEVIN WOOD
Credential	:
Telephone Number	:	573-335-8207

Provider Enumeration Date	:	09/16/2020
Last Update Date	:	09/16/2020

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Directions to “SCOTT CITY SUNSHINE LLC ” Practice Location

Language	Start Address	Practice Location

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