Healthcare Provider Details

I. General information

NPI: 1093297673
Provider Name (Legal Business Name): SUNRISE DETOX MILLBURY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 MAIN ST
MILLBURY MA
01527-2005
US

IV. Provider business mailing address

PO BOX 12586
NEWARK NJ
07101-3562
US

V. Phone/Fax

Practice location:
  • Phone: 508-581-5225
  • Fax: 508-865-2823
Mailing address:
  • Phone: 508-581-5225
  • Fax: 508-865-2823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH M CHELALES
Title or Position: ADMINISTRATOR
Credential:
Phone: 646-285-4035