Provider Demographics
NPI:1396374674
Name:SHINE PLACE
Entity Type:Organization
Organization Name:SHINE PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LECIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ICARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-600-6003
Mailing Address - Street 1:336 WINEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-5956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:336 WINEWOOD ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-5956
Practice Address - Country:US
Practice Address - Phone:619-600-6003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility