MEDICARE: SUNRISE COMMUNITY OF POLK COUNTY, INC.

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619018454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE COMMUNITY OF POLK COUNTY, INC.

Provider Business Mailing Address
First Line	:	807 N LAKE PARKER AVE
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-2044
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	807 N LAKE PARKER AVE
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-2044
Country	:	US
Telephone Number	:	863-680-2817
Fax Number	:

Authorized Official
Title or Position	:	BOARD SECRETARY
Name	:	DR. JAMES WEEKS
Credential	:
Telephone Number	:	305-273-3024

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	08/22/2020

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