Provider Demographics
NPI:1447304746
Name:SUNRISE THIRD (POOL IV), LLC
Entity type:Organization
Organization Name:SUNRISE THIRD (POOL IV), LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GEDBAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-542-9000
Mailing Address - Street 1:404 KING GEORGE RD
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-2808
Mailing Address - Country:US
Mailing Address - Phone:908-542-9000
Mailing Address - Fax:
Practice Address - Street 1:404 KING GEORGE RD
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-2808
Practice Address - Country:US
Practice Address - Phone:908-542-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ80A008310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8937001Medicaid