Provider Demographics
NPI:1437473063
Name:SUNSHINE ICF DDN
Entity Type:Organization
Organization Name:SUNSHINE ICF DDN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:P
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-598-1436
Mailing Address - Street 1:1701 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-2916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 W ELM ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-2916
Practice Address - Country:US
Practice Address - Phone:209-598-1436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55GP1907320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55GP1907OtherMEDI-CAL PROVIDER