Provider Demographics
NPI:1992321095
Name:SASS.ILLY ENDEAVORS, INC.
Entity type:Organization
Organization Name:SASS.ILLY ENDEAVORS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHASTA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-243-0011
Mailing Address - Street 1:1300 METRO EAST DR STE 110
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:IA
Mailing Address - Zip Code:50327-8906
Mailing Address - Country:US
Mailing Address - Phone:515-243-0011
Mailing Address - Fax:515-243-7711
Practice Address - Street 1:1300 METRO EAST DR STE 110
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:IA
Practice Address - Zip Code:50327-8906
Practice Address - Country:US
Practice Address - Phone:515-243-0011
Practice Address - Fax:515-243-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-24
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAX000222090Medicaid