Provider Demographics
NPI:1609606805
Name:SUNRISE YOUTH SERVICES INC
Entity type:Organization
Organization Name:SUNRISE YOUTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MASON
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-639-3356
Mailing Address - Street 1:112 UNIVERSITY DR N STE L140
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4635
Mailing Address - Country:US
Mailing Address - Phone:701-639-3356
Mailing Address - Fax:
Practice Address - Street 1:112 UNIVERSITY DR N STE L140
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4635
Practice Address - Country:US
Practice Address - Phone:701-639-3356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-03
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty