Basic Information
| Provider Information | |||||||||
| NPI: | 1558844910 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNRISE TREATMENT CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUNRISE TREATMENT CENTER. LLC CORPORATE OFFICE (OH MH) | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 6460 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452477957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139414999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2018 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | HENRY. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5133725923 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPCC-S, LICDC-CS | ||||||||
| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0313320 | 05 | OH | MEDICAID |