Provider Demographics
NPI:1629785159
Name:SUNDANCE ADULT FAMILY HOME LLC
Entity Type:Organization
Organization Name:SUNDANCE ADULT FAMILY HOME LLC
Other - Org Name:SUNDANCE ADULT FAMILY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MWIKLAI
Authorized Official - Last Name:WAWERU
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:508-612-3875
Mailing Address - Street 1:10216 N SUNDANCE DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-9315
Mailing Address - Country:US
Mailing Address - Phone:509-315-5779
Mailing Address - Fax:509-984-6291
Practice Address - Street 1:10216 N SUNDANCE DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-9315
Practice Address - Country:US
Practice Address - Phone:509-315-5779
Practice Address - Fax:509-984-6291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-03
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home