Basic Information
Provider Information | |||||||||
NPI: | 1417444399 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUNRISE TREATMENT CENTER - MIDDLETOWN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6460 HARRISON AVE. SUITE 200 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452477958 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5134672825 | ||||||||
FaxNumber: | 5139417555 | ||||||||
Practice Location | |||||||||
Address1: | 160 N BREIEL BLVD | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | OH | ||||||||
PostalCode: | 450423806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5139414999 | ||||||||
FaxNumber: | 5139417555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2018 | ||||||||
LastUpdateDate: | 03/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SPAULDING | ||||||||
AuthorizedOfficialFirstName: | RANDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACT & PROVIDER RELATIONS MGR. | ||||||||
AuthorizedOfficialTelephone: | 5134672825 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SUNRISE TREATMENT CENTER, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 | 0078786 | 05 | OH |   | MEDICAID | 0313320 | 05 | OH |   | MEDICAID |