Basic Information
| Provider Information | |||||||||
| NPI: | 1508828120 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNNY KNOLL CARE CENTER, LLC | ||||||||
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| OtherOrganizationName: | SUNNY KNOLL CARE CENTER, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5115 E STATE ROAD 64 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342085509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417584745 | ||||||||
| FaxNumber: | 9417512135 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 WARNER ST | ||||||||
| Address2: | |||||||||
| City: | ROCKWELL CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505791722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122978918 | ||||||||
| FaxNumber: | 7122975535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENCH | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 9417584745 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 130168 | IA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0803858 | 05 | IA | MEDICAID | 0800076 | 05 | IA | MEDICAID |