Provider Demographics
NPI:1992043053
Name:SUNRISE TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:SUNRISE TREATMENT CENTER, LLC
Other - Org Name:SUNRISE TREATMENT CENTER - WEST SIDE
Other - Org Type:Other Name
Authorized Official - Title/Position:COO/CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPAULDING
Authorized Official - Suffix:
Authorized Official - Credentials:LICDC
Authorized Official - Phone:513-467-2825
Mailing Address - Street 1:6460 HARRISON AVE. SUITE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7957
Mailing Address - Country:US
Mailing Address - Phone:513-467-2825
Mailing Address - Fax:513-941-7555
Practice Address - Street 1:6460 HARRISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247-7958
Practice Address - Country:US
Practice Address - Phone:513-941-4999
Practice Address - Fax:513-941-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0078786Medicaid
OH0313320Medicaid