Provider Demographics
NPI:1619599503
Name:SUCCESSOR HEALTHCARE LLC
Entity Type:Organization
Organization Name:SUCCESSOR HEALTHCARE LLC
Other - Org Name:ST. JOSEPH INDEPENDENT LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:451 E BISHOP FEDERAL LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2357
Mailing Address - Country:US
Mailing Address - Phone:801-487-7557
Mailing Address - Fax:801-487-1112
Practice Address - Street 1:451 E BISHOP FEDERAL LN
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2357
Practice Address - Country:US
Practice Address - Phone:801-487-7557
Practice Address - Fax:801-487-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility