Provider Demographics
NPI:1992906408
Name:SUNSHINE ASSISTED LIVING
Entity type:Organization
Organization Name:SUNSHINE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ENID
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-753-9428
Mailing Address - Street 1:1815 AIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4004
Mailing Address - Country:US
Mailing Address - Phone:928-753-9428
Mailing Address - Fax:928-565-7472
Practice Address - Street 1:1815 AIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4004
Practice Address - Country:US
Practice Address - Phone:928-753-9428
Practice Address - Fax:928-565-7472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH6156311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ204833Medicaid