Provider Demographics
NPI:1437104916
Name:SUNRISE PRIMARY CARE INC
Entity Type:Organization
Organization Name:SUNRISE PRIMARY CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:
Authorized Official - First Name:MARIA-JOSEFINA
Authorized Official - Middle Name:S
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-698-2279
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32178-0249
Mailing Address - Country:US
Mailing Address - Phone:386-698-2279
Mailing Address - Fax:386-698-2239
Practice Address - Street 1:811 NORTH SUMMIT ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-2407
Practice Address - Country:US
Practice Address - Phone:386-698-2279
Practice Address - Fax:386-698-2239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76342261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660181200Medicaid
FL660181200Medicaid