Healthcare Provider Details

I. General information

NPI: 1023075561
Provider Name (Legal Business Name): SUNRISE LIFESTYLE CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

658 KENILWORTH DR SUITE 100
TOWSON MD
21204-2312
US

IV. Provider business mailing address

40 SKOKIE BLVD SUITE 440
NORTHBROOK IL
60062-1601
US

V. Phone/Fax

Practice location:
  • Phone: 410-296-4901
  • Fax: 410-296-4971
Mailing address:
  • Phone: 847-656-0353
  • Fax: 847-656-0358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number StateMD

VIII. Authorized Official

Name: JEFF T GRADE
Title or Position: CEO
Credential:
Phone: 847-656-0353