Provider Demographics
NPI:1700135399
Name:SUNRISE DETOX III, LLC
Entity Type:Organization
Organization Name:SUNRISE DETOX III, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:USILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-318-4400
Mailing Address - Street 1:2328 10TH AVE N
Mailing Address - Street 2:#301
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6606
Mailing Address - Country:US
Mailing Address - Phone:561-318-4414
Mailing Address - Fax:561-533-3832
Practice Address - Street 1:2331 NE 53RD ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3235
Practice Address - Country:US
Practice Address - Phone:954-491-9700
Practice Address - Fax:561-228-0836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320800000X
FL1706AD576201324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility