Provider Demographics
NPI:1730254145
Name:SUNRISE SHOES & PEDORTHIC SERVICE
Entity type:Organization
Organization Name:SUNRISE SHOES & PEDORTHIC SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:NICHOLLE
Authorized Official - Last Name:DURANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-368-7700
Mailing Address - Street 1:3127 FITE CIR
Mailing Address - Street 2:SUITE G
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-1803
Mailing Address - Country:US
Mailing Address - Phone:916-368-7700
Mailing Address - Fax:916-368-7717
Practice Address - Street 1:3127 FITE CIR
Practice Address - Street 2:SUITE G
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-1803
Practice Address - Country:US
Practice Address - Phone:916-368-7700
Practice Address - Fax:916-368-7717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000820Medicaid
CA0127817OtherKAISER
CA0929710002Medicare UPIN
CA0929710002Medicare UPIN