Basic Information
| Provider Information | |||||||||
| NPI: | 1174730105 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUN VILLAIDENCE OPCO, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SEQUOIA TRANSITIONAL CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 N UNION AVE STE 320 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840252956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014479829 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 350 N VILLA ST | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932573211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597846644 | ||||||||
| FaxNumber: | 5597843178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANCOCK | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8014479829 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 120000589 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT05551I | 05 | CA | MEDICAID |