MEDICARE: SUNRISE DETOX DULUTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility
2	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1649914813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE DETOX DULUTH, LLC

Provider Business Mailing Address
First Line	:	2328 10TH AVE N STE 300
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-6612
Country	:	US
Telephone Number	:	561-318-4400
Fax Number	:

Provider Business Practice Location Address
First Line	:	3390 N BERKELEY LAKE RD NW
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-3006
Country	:	US
Telephone Number	:	561-318-4400
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF RCM
Name	:	MR. JASON USILTON
Credential	:
Telephone Number	:	561-318-4400

Provider Enumeration Date	:	04/25/2022
Last Update Date	:	10/05/2023

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