Provider Demographics
NPI:1609332394
Name:SUNSET SHORELINE
Entity Type:Organization
Organization Name:SUNSET SHORELINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:KILLEBREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-698-4500
Mailing Address - Street 1:1501 WESTCLIFF DR STE 309
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5519
Mailing Address - Country:US
Mailing Address - Phone:714-698-4500
Mailing Address - Fax:
Practice Address - Street 1:1501 WESTCLIFF DR STE 309
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5519
Practice Address - Country:US
Practice Address - Phone:714-698-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-18
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory