Basic Information
Provider Information | |||||||||
NPI: | 1891221271 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUNRISE COMMUNITY OF TENNESSEE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9040 SUNSET DR | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331733432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055969040 | ||||||||
FaxNumber: | 3052753345 | ||||||||
Practice Location | |||||||||
Address1: | 640 OLD SHILOH RD | ||||||||
Address2: |   | ||||||||
City: | GREENEVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 377450556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4233293973 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2017 | ||||||||
LastUpdateDate: | 05/04/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAVIDSON | ||||||||
AuthorizedOfficialFirstName: | KAREN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER/CFO | ||||||||
AuthorizedOfficialTelephone: | 3052733023 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MACC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | L000000015489 | TN | Y |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |   |
ID Information
ID | Type | State | Issuer | Description | L000000015489 | 01 | TN | STATE OF TENNESSEE DEPARTMENT OF INTELLECTUAL & DEVELOPMENTAL DISABILITIES | OTHER |