Basic Information
| Provider Information | |||||||||
| NPI: | 1689671158 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNSET KNOLL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SUNSET KNOLL CARE AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 401 WEST 5TH STREET | ||||||||
| Address2: | |||||||||
| City: | AURELIA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 510050067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7124342294 | ||||||||
| FaxNumber: | 7124342153 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 WEST 5TH STREET | ||||||||
| Address2: | |||||||||
| City: | AURELIA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 510050067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7124342294 | ||||||||
| FaxNumber: | 7124342153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7124342294 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 165535 | IA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 180325 | IA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0803940 | 05 | IA | MEDICAID |