Healthcare Provider Details

I. General information

NPI: 1396223780
Provider Name (Legal Business Name): SUNRISE SENIOR SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 146TH ST FL 2
FLUSHING NY
11354-4267
US

IV. Provider business mailing address

3520 146TH ST FL 2
FLUSHING NY
11354-4267
US

V. Phone/Fax

Practice location:
  • Phone: 929-595-6013
  • Fax:
Mailing address:
  • Phone: 929-595-6013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. TAEYOUNG SONG
Title or Position: PRESIDENT
Credential:
Phone: 929-595-6013