MEDICARE: SUNLYTE TREATMENT CENTERS

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	363LA2200X	Adult Health Nurse Practitioner
2	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1033704630
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNLYTE TREATMENT CENTERS

Provider Business Mailing Address
First Line	:	1123 KERPER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111-4925
Country	:	US
Telephone Number	:	215-205-2294
Fax Number	:

Provider Business Practice Location Address
First Line	:	2556 N FRONT ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-4004
Country	:	US
Telephone Number	:	215-205-2294
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JANELL L. CLARK
Credential	:	APN-BC
Telephone Number	:	215-205-2294

Provider Enumeration Date	:	03/04/2021
Last Update Date	:	05/13/2021

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