MEDICARE: SUNRISE SUPPLY RESOURCE 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1770100869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE SUPPLY RESOURCE LLC

Provider Business Mailing Address
First Line	:	1975 E SUNRISE BLVD STE 608
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33304-1453
Country	:	US
Telephone Number	:	561-437-6669
Fax Number	:

Provider Business Practice Location Address
First Line	:	1975 E SUNRISE BLVD STE 608
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33304-1453
Country	:	US
Telephone Number	:	561-437-6669
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANTHONY VESPUCCI
Credential	:
Telephone Number	:	561-437-6669

Provider Enumeration Date	:	07/06/2020
Last Update Date	:	07/06/2020

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