Basic Information
| Provider Information | |||||||||
| NPI: | 1164549861 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNSHINE COMMUNITY HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SUNSHINE CARE CONNECTION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 787 | ||||||||
| Address2: | |||||||||
| City: | TALKEETNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996760787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077339207 | ||||||||
| FaxNumber: | 9077331735 | ||||||||
| Practice Location | |||||||||
| Address1: | MILE 4.5 TALKEETNA SPUR ROAD | ||||||||
| Address2: | |||||||||
| City: | TALKEETNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077332273 | ||||||||
| FaxNumber: | 9077331935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JORGENSEN | ||||||||
| AuthorizedOfficialFirstName: | SHELIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9077339207 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ANP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 77895 | AK | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | CMG3761 | 05 | AK | MEDICAID |