Provider Demographics
NPI:1114451648
Name:SUNTERRA INDEPENDENCE OC, LLC
Entity Type:Organization
Organization Name:SUNTERRA INDEPENDENCE OC, LLC
Other - Org Name:SUNTERRA SPRINGS INDEPENDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GOVERNING BODY CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNOWBALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-397-4000
Mailing Address - Street 1:598 W 900 S STE 220
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8195
Mailing Address - Country:US
Mailing Address - Phone:801-397-4697
Mailing Address - Fax:801-293-9117
Practice Address - Street 1:19200 E 37TH TERRACE S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-8324
Practice Address - Country:US
Practice Address - Phone:816-335-3007
Practice Address - Fax:816-335-3023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
MO14674 6314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility