Provider Demographics
NPI:1679626733
Name:SUNRISE COSMED, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SUNRISE COSMED, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AZADEH
Authorized Official - Middle Name:
Authorized Official - Last Name:MODARESI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-668-8898
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-0547
Mailing Address - Country:US
Mailing Address - Phone:818-668-8898
Mailing Address - Fax:818-668-8893
Practice Address - Street 1:6730A WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-5359
Practice Address - Country:US
Practice Address - Phone:818-668-8898
Practice Address - Fax:818-668-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70235261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center