Provider Demographics
NPI:1235665175
Name:SUNRISE CLINICAL LAB, LLC
Entity Type:Organization
Organization Name:SUNRISE CLINICAL LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TUSEEAF
Authorized Official - Middle Name:T
Authorized Official - Last Name:RATHORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-668-5016
Mailing Address - Street 1:22 BALL ST
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3521
Mailing Address - Country:US
Mailing Address - Phone:973-757-2184
Mailing Address - Fax:973-757-2022
Practice Address - Street 1:22 BALL ST
Practice Address - Street 2:SUITE # 2
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3521
Practice Address - Country:US
Practice Address - Phone:973-757-2184
Practice Address - Fax:973-757-2022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ00043167291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0464848Medicaid