Provider Demographics
NPI:1023075561
Name:SUNRISE LIFESTYLE CENTERS LLC
Entity type:Organization
Organization Name:SUNRISE LIFESTYLE CENTERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:T
Authorized Official - Last Name:GRADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-656-0353
Mailing Address - Street 1:40 SKOKIE BLVD
Mailing Address - Street 2:SUITE 440
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1601
Mailing Address - Country:US
Mailing Address - Phone:847-656-0353
Mailing Address - Fax:847-656-0358
Practice Address - Street 1:658 KENILWORTH DR
Practice Address - Street 2:SUITE 100
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2312
Practice Address - Country:US
Practice Address - Phone:410-296-4901
Practice Address - Fax:410-296-4971
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNRISE LIFESTYLE CENTERS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-27
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0400X, 261QP2000X
MD261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21-4530OtherMEDICARE PROVIDER #
MD21-4530OtherMEDICARE PROVIDER #