Provider Demographics
NPI:1003091323
Name:MIKOUIS ENTERPRISES, INC., DBA SUNRISE HOMES
Entity type:Organization
Organization Name:MIKOUIS ENTERPRISES, INC., DBA SUNRISE HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKOUIS
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA, RD/LD, RN
Authorized Official - Phone:330-424-1418
Mailing Address - Street 1:38655 SALTWELL RD
Mailing Address - Street 2:P.O. BOX 329
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-8348
Mailing Address - Country:US
Mailing Address - Phone:330-424-1418
Mailing Address - Fax:330-424-1920
Practice Address - Street 1:38655 SALTWELL RD
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-8348
Practice Address - Country:US
Practice Address - Phone:330-424-1418
Practice Address - Fax:330-424-1920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-05
Last Update Date:2008-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH24817315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0115048Medicaid