Provider Demographics
NPI:1447244959
Name:SUNRISE CLINICAL LABORATORY
Entity Type:Organization
Organization Name:SUNRISE CLINICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIFTAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KEMAL
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:941-624-3005
Mailing Address - Street 1:21216 OLEAN BLVD
Mailing Address - Street 2:3
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6722
Mailing Address - Country:US
Mailing Address - Phone:941-624-3005
Mailing Address - Fax:941-624-6405
Practice Address - Street 1:21216 OLEAN BLVD
Practice Address - Street 2:3
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6722
Practice Address - Country:US
Practice Address - Phone:941-624-3005
Practice Address - Fax:941-624-6405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL9263OtherBCBS
FLL9263Medicare ID - Type Unspecified
FLL9263OtherBCBS
FLY18922Medicare UPIN