=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316932569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNRISE COUNTRY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2005
-----------------------------------------------------
Last Update Date | 11/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 224TH RD
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68405-8475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-761-3230
-----------------------------------------------------
Fax | 402-761-3283
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 224TH RD
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68405-8475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-761-3230
-----------------------------------------------------
Fax | 402-761-3283
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. LEMAR TIM STAUFFER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-761-3230
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 724002
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------