Provider Demographics
NPI:1093159402
Name:SUNRISE THIRD WEST BLOOMFIELD SL, LLC
Entity Type:Organization
Organization Name:SUNRISE THIRD WEST BLOOMFIELD SL, LLC
Other - Org Name:SUNRISE OF WEST BLOOMFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMERA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-738-8101
Mailing Address - Street 1:7005 PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2181
Mailing Address - Country:US
Mailing Address - Phone:248-738-8101
Mailing Address - Fax:248-738-8177
Practice Address - Street 1:7005 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2181
Practice Address - Country:US
Practice Address - Phone:248-738-8101
Practice Address - Fax:248-738-8177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAH630297112310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility