Provider Demographics
NPI:1427304633
Name:SUNSHINE DREAMASSISTED LIVING LLC
Entity type:Organization
Organization Name:SUNSHINE DREAMASSISTED LIVING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-510-3888
Mailing Address - Street 1:4841 LENORA CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-7707
Mailing Address - Country:US
Mailing Address - Phone:404-510-3888
Mailing Address - Fax:678-344-4261
Practice Address - Street 1:4841 LENORA CHURCH RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-7707
Practice Address - Country:US
Practice Address - Phone:404-510-3888
Practice Address - Fax:678-344-4261
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNSHINE DREAM ASSISTED LIVING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACLA000930251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124871AMedicaid