Provider Demographics
NPI:1396551016
Name:SUNSHINE LEGACY ASSISTED LIVING LLC
Entity type:Organization
Organization Name:SUNSHINE LEGACY ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KETCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-597-3870
Mailing Address - Street 1:1532 W CHARLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-2507
Mailing Address - Country:US
Mailing Address - Phone:480-597-3870
Mailing Address - Fax:
Practice Address - Street 1:1532 W CHARLESTON AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-2507
Practice Address - Country:US
Practice Address - Phone:480-597-3870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility