MEDICARE: SUNRISE HEALTHCARE CORPORATION

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	314000000X	Skilled Nursing Facility	0000000264	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	62647	OTHER	TN	BLUE CROSS/BLUE SHIELD OF
2	330690226	OTHER		JOHN DEERE
3	330690226	OTHER		ADVENTA HOSPICE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386691889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE HEALTHCARE CORPORATION

Provider Business Mailing Address
First Line	:	101 SUN AVE NE
Second Line	:	COMPLIANCE DEPARTMENT
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4373
Country	:	US
Telephone Number	:	505-468-5604
Fax Number	:	505-468-4681

Provider Business Practice Location Address
First Line	:	3641 MEMORIAL BLVD
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-3422
Country	:	US
Telephone Number	:	423-246-2411
Fax Number	:	423-246-8997

Authorized Official
Title or Position	:	PRESIDENT DIRECTOR
Name	:	WILLIAM A MATHIES
Credential	:
Telephone Number	:	505-821-3355

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	07/01/2008

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Directions to “SUNRISE HEALTHCARE CORPORATION ” Practice Location

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