Provider Demographics
NPI:1366688707
Name:SUNRISE SHOES AND PEDORTHIC SRVC CORP
Entity Type:Organization
Organization Name:SUNRISE SHOES AND PEDORTHIC SRVC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:S
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:916-368-7700
Mailing Address - Street 1:3127 FITE CIR STE G
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-1803
Mailing Address - Country:US
Mailing Address - Phone:916-368-7700
Mailing Address - Fax:916-368-7717
Practice Address - Street 1:5333 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3539
Practice Address - Country:US
Practice Address - Phone:916-368-7700
Practice Address - Fax:916-368-7717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0929710001Medicare NSC