MEDICARE: SUNRISE VISTA, 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	156FX1800X	Optician

General Provider Information

NPI Number	:	1609235431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE VISTA, LLC

Provider Business Mailing Address
First Line	:	18850 S MEMORIAL DR
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77338-4288
Country	:	US
Telephone Number	:	281-446-7900
Fax Number	:

Provider Business Practice Location Address
First Line	:	6860 HIGHWAY 6 N
Second Line	:	SUITE A
City	:	HOUSTON
State	:	TX
Zip	:	77084-1342
Country	:	US
Telephone Number	:	281-500-9605
Fax Number	:	281-500-9611

Authorized Official
Title or Position	:	CREDENTIALING COORD
Name	:	JIMMY PRICE
Credential	:
Telephone Number	:	281-500-9606

Provider Enumeration Date	:	02/22/2016
Last Update Date	:	02/22/2016

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Directions to “SUNRISE VISTA, LLC ” Practice Location

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