Provider Demographics
NPI:1093297673
Name:SUNRISE DETOX MILLBURY LLC
Entity Type:Organization
Organization Name:SUNRISE DETOX MILLBURY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHELALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-285-4035
Mailing Address - Street 1:PO BOX 12586
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-3562
Mailing Address - Country:US
Mailing Address - Phone:508-581-5225
Mailing Address - Fax:508-865-2823
Practice Address - Street 1:29 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:MA
Practice Address - Zip Code:01527-2005
Practice Address - Country:US
Practice Address - Phone:508-581-5225
Practice Address - Fax:508-865-2823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAXX-XXX9587OtherTIN