MEDICARE: SUNRIDGE ENTERPRISE 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	320800000X	Mental Illness Community Based Residential Treatment Facility	NV20141482582	NV

General Provider Information

NPI Number	:	1740684984
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRIDGE ENTERPRISE INC.

Provider Business Mailing Address
First Line	:	2128 PINK CORAL DR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-0985
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2128 PINK CORAL DR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-0985
Country	:	US
Telephone Number	:	702-234-9822
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES ELDRIDGE
Credential	:
Telephone Number	:	702-557-4436

Provider Enumeration Date	:	10/17/2014
Last Update Date	:	11/03/2014

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