Provider Demographics
NPI:1386135762
Name:SUNRISE FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:SUNRISE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOLOLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:385-645-7474
Mailing Address - Street 1:8785 S JORDAN VALLEY WAY # 100
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9772
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8785 S JORDAN VALLEY WAY # 100
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9772
Practice Address - Country:US
Practice Address - Phone:385-645-7474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT211972-4405261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care