Basic Information
| Provider Information | |||||||||
| NPI: | 1316244692 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNRISE COMMUNITY HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2930 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806201011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703539403 | ||||||||
| FaxNumber: | 9703539906 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 N 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806319117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703046425 | ||||||||
| FaxNumber: | 9703046416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MORAN | ||||||||
| AuthorizedOfficialFirstName: | MITZI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9703504606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNRISE COMMUNITY HEALTH | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 48277347 | 05 | CO | MEDICAID |