Healthcare Provider Details

I. General information

NPI: 1750432977
Provider Name (Legal Business Name): SUNRISE THIRD (POOL III), LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 NEWMAN SPRINGS RD
LINCROFT NJ
07738-1523
US

IV. Provider business mailing address

734 NEWMAN SPRINGS RD
LINCROFT NJ
07738-1523
US

V. Phone/Fax

Practice location:
  • Phone: 732-212-1910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberCOGCWM
License Number StateNJ

VIII. Authorized Official

Name: JACQUELINE FIX
Title or Position: EXECUTIVE DIRECTOR
Credential: ALA
Phone: 732-212-1910