Basic Information
| Provider Information | |||||||||
| NPI: | 1710340807 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNRISE TREATMENT CENTER - LABORATORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6460 HARRISON AVE. SUITE 200 | ||||||||
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| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452472019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134672825 | ||||||||
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| Practice Location | |||||||||
| Address1: | 680 NORTHLAND BLVD | ||||||||
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| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452403248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139414999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO/CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5139414999 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNRISE TREATMENT CENTER, LLC | ||||||||
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| AuthorizedOfficialCredential: | LPC, LICDC-CS | ||||||||
| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0078786 | 05 | OH | MEDICAID |