Provider Demographics
NPI:1073642419
Name:SUNRISE PRIMARY CARE INC
Entity Type:Organization
Organization Name:SUNRISE PRIMARY CARE INC
Other - Org Name:SUNRISE PRIMARY CARE INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA-JOSEFINA
Authorized Official - Middle Name:S
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-325-8002
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32178-0249
Mailing Address - Country:US
Mailing Address - Phone:386-325-8002
Mailing Address - Fax:386-325-8055
Practice Address - Street 1:219 N PALM AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-2627
Practice Address - Country:US
Practice Address - Phone:386-325-8002
Practice Address - Fax:386-325-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-03
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 76342207Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660236300Medicaid
FL660236300Medicaid