Healthcare Provider Details

I. General information

NPI: 1073282117
Provider Name (Legal Business Name): SUNRISE FOR A HAPPY LIFE ADC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2021
Last Update Date: 09/11/2021
Certification Date: 09/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 N LAKE PARKER AVE
LAKELAND FL
33801-2044
US

IV. Provider business mailing address

410 W HANCOCK ST
LAKELAND FL
33803-1418
US

V. Phone/Fax

Practice location:
  • Phone: 863-614-6136
  • Fax: 863-337-6638
Mailing address:
  • Phone: 863-272-3852
  • Fax: 863-337-6638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARTHA I PONGUTA
Title or Position: ADMINISTRATOR
Credential:
Phone: 863-272-3852