Provider Demographics
NPI:1356883243
Name:RISING SUN MODERN MEDICINE
Entity type:Organization
Organization Name:RISING SUN MODERN MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:LOCK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN FNP-BC
Authorized Official - Phone:812-221-0332
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:RISING SUN
Mailing Address - State:IN
Mailing Address - Zip Code:47040-0026
Mailing Address - Country:US
Mailing Address - Phone:812-438-1216
Mailing Address - Fax:812-438-1252
Practice Address - Street 1:120 N WALNUT ST
Practice Address - Street 2:SUITE A
Practice Address - City:RISING SUN
Practice Address - State:IN
Practice Address - Zip Code:47040-1276
Practice Address - Country:US
Practice Address - Phone:812-438-1216
Practice Address - Fax:812-438-1252
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAWRENCEBURG URGENT CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004143A261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care