Provider Demographics
NPI:1700261633
Name:SHINE SENIOR CENTER
Entity Type:Organization
Organization Name:SHINE SENIOR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEONGBOK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-821-7214
Mailing Address - Street 1:9198 RED BRANCH RD STE H
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2017
Mailing Address - Country:US
Mailing Address - Phone:301-310-3067
Mailing Address - Fax:410-772-3933
Practice Address - Street 1:9198 RED BRANCH RD STE H
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2017
Practice Address - Country:US
Practice Address - Phone:301-310-3067
Practice Address - Fax:410-772-3933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTBA261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care