Provider Demographics
NPI:1003941964
Name:SUNSHINE THERAPY CLUB, INC
Entity Type:Organization
Organization Name:SUNSHINE THERAPY CLUB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TARAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-853-9919
Mailing Address - Street 1:410 W TOWNSHIP LINE ROAD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083
Mailing Address - Country:US
Mailing Address - Phone:610-853-9918
Mailing Address - Fax:610-853-9921
Practice Address - Street 1:410 W TOWNSHIP LINE ROAD
Practice Address - Street 2:SUITE 4
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083
Practice Address - Country:US
Practice Address - Phone:610-853-9918
Practice Address - Fax:610-853-9921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000061970007Medicaid