Basic Information
| Provider Information | |||||||||
| NPI: | 1205435369 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNRISE TREATMENT CENTER - OTR | ||||||||
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| OtherOrganizationName: | SUNRISE TREATMENT CENTER - OTR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6460 HARRISON AVE. SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452477957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134672825 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1718 CENTRAL PKWY | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452142355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139414999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2020 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | HENRY. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5134673772 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNRISE TREATMENT CENTER, LLC | ||||||||
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| AuthorizedOfficialCredential: | LPCC-S, LICDC-CS | ||||||||
| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 0313320 | 05 | OH | MEDICAID | 0078786 | 05 | OH | MEDICAID |