Healthcare Provider Details

I. General information

NPI: 1669864930
Provider Name (Legal Business Name): SUNRISE MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 S EASTERN AVE SUITE B17
LAS VEGAS NV
89119-6182
US

IV. Provider business mailing address

4560 S EASTERN AVE SUITE B17
LAS VEGAS NV
89119-6182
US

V. Phone/Fax

Practice location:
  • Phone: 832-554-6595
  • Fax:
Mailing address:
  • Phone: 832-554-6595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CORNELL SMITH
Title or Position: ADMINISTRATOR
Credential:
Phone: 832-554-6595