Provider Demographics
NPI:1417347113
Name:SUNSHINE TERRANCE
Entity Type:Organization
Organization Name:SUNSHINE TERRANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:435-512-9071
Mailing Address - Street 1:1277 E 100 S
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4974
Mailing Address - Country:US
Mailing Address - Phone:435-512-9071
Mailing Address - Fax:
Practice Address - Street 1:209 W 300 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-3809
Practice Address - Country:US
Practice Address - Phone:435-716-8535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT92879094201261QC1500X, 261QM1300X, 261QR0400X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT92879094201Medicaid
UT9287909-4201Medicaid
UT92879094201Medicaid
UT92879094201Medicare Oscar/Certification