MEDICARE: SUNRISE DETOX DULUTH GA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility
2	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1013859271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE DETOX DULUTH GA, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1575
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-1018
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3390 N BERKELEY LAKE RD NW STE A
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-3006
Country	:	US
Telephone Number	:	561-318-4400
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	JOEL HERSKO
Credential	:
Telephone Number	:	347-661-0013

Provider Enumeration Date	:	04/07/2026
Last Update Date	:	04/07/2026

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