MEDICARE: SUNNY SPIRITS ASSISTED LIVING

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	121662	TX

General Provider Information

NPI Number	:	1851543847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNNY SPIRITS ASSISTED LIVING

Provider Business Mailing Address
First Line	:	710 FENWICK DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78239-2634
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 FENWICK DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78239-2634
Country	:	US
Telephone Number	:	210-590-8961
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HENRY CHARLES MONCADA
Credential	:
Telephone Number	:	210-618-5203

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	10/21/2008

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