Provider Demographics
NPI:1972813848
Name:TREMAYNE SHANKAR AND KENNEDY-FUNTILA A PROFESSIONAL MED
Entity Type:Organization
Organization Name:TREMAYNE SHANKAR AND KENNEDY-FUNTILA A PROFESSIONAL MED
Other - Org Name:SUNRISE CENTER FOR MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:TREMAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-629-6468
Mailing Address - Street 1:1600 SUNRISE AVE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4679
Mailing Address - Country:US
Mailing Address - Phone:209-629-6468
Mailing Address - Fax:209-578-1088
Practice Address - Street 1:1600 SUNRISE AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4679
Practice Address - Country:US
Practice Address - Phone:209-629-6468
Practice Address - Fax:209-578-1088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty