Provider Demographics
NPI:1891807277
Name:SUNRISE PRIMARY CARE SERVICES INC
Entity Type:Organization
Organization Name:SUNRISE PRIMARY CARE SERVICES INC
Other - Org Name:CREST HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLIARDT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:830-331-2005
Mailing Address - Street 1:604 N. MAIN STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-9999
Mailing Address - Country:US
Mailing Address - Phone:830-331-2005
Mailing Address - Fax:830-331-2045
Practice Address - Street 1:1100 N MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-3086
Practice Address - Country:US
Practice Address - Phone:830-331-2005
Practice Address - Fax:830-331-2045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008948251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173390901Medicaid
67-3124Medicare UPIN
TX673124Medicare Oscar/Certification