Healthcare Provider Details

I. General information

NPI: 1376929208
Provider Name (Legal Business Name): SUNRISE PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4721 HIAWATHA AVE
MINNEAPOLIS MN
55406-3928
US

IV. Provider business mailing address

4721 HIAWATHA AVE
MINNEAPOLIS MN
55406-3928
US

V. Phone/Fax

Practice location:
  • Phone: 612-822-1720
  • Fax:
Mailing address:
  • Phone: 612-822-1720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1074667
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1074667
License Number StateMN

VIII. Authorized Official

Name: CHRISTIANA GREENE
Title or Position: PRESIDENT
Credential:
Phone: 612-328-4819