Provider Demographics
NPI:1336556000
Name:SUN RISE AGENCY LLC
Entity Type:Organization
Organization Name:SUN RISE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALPHA
Authorized Official - Middle Name:
Authorized Official - Last Name:TONGOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-772-3106
Mailing Address - Street 1:3301 E MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3301 E MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2740
Practice Address - Country:US
Practice Address - Phone:614-772-3106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization