Provider Demographics
NPI:1982032413
Name:SUNRISE DIAGNOSTIC, INC.
Entity Type:Organization
Organization Name:SUNRISE DIAGNOSTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-326-6855
Mailing Address - Street 1:2500 E BALL RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-5054
Mailing Address - Country:US
Mailing Address - Phone:562-366-3388
Mailing Address - Fax:866-214-8477
Practice Address - Street 1:2500 E BALL RD
Practice Address - Street 2:SUITE 220
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-5054
Practice Address - Country:US
Practice Address - Phone:562-366-3388
Practice Address - Fax:866-214-8477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11362208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty