Provider Demographics
NPI:1063807113
Name:SUNDANCE LIFE ENRICHMENT, INC.
Entity type:Organization
Organization Name:SUNDANCE LIFE ENRICHMENT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHINNEY RIDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-401-2078
Mailing Address - Street 1:PO BOX 1525
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-1525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3875 TAYLOR RD STE 204G
Practice Address - Street 2:
Practice Address - City:LOOMIS
Practice Address - State:CA
Practice Address - Zip Code:95650-9273
Practice Address - Country:US
Practice Address - Phone:530-401-2078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-04
Last Update Date:2015-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50023106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty