Provider Demographics
NPI:1164583704
Name:SUNRISE PROSTHETICS AND ORTHOTICS
Entity Type:Organization
Organization Name:SUNRISE PROSTHETICS AND ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:601-414-0032
Mailing Address - Street 1:1221 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2018
Mailing Address - Country:US
Mailing Address - Phone:601-414-0032
Mailing Address - Fax:
Practice Address - Street 1:1221 N WEST ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2018
Practice Address - Country:US
Practice Address - Phone:601-414-0032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0527106332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03959826Medicaid
MS03959826Medicaid