Provider Demographics
NPI:1376193425
Name:SANDY SPORTSCARE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SANDY SPORTSCARE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER AND CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DOMONIQUE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RUSCITTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-274-2861
Mailing Address - Street 1:16621 CHAMPION WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-7258
Mailing Address - Country:US
Mailing Address - Phone:503-668-5321
Mailing Address - Fax:
Practice Address - Street 1:16621 CHAMPION WAY STE 100
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-7258
Practice Address - Country:US
Practice Address - Phone:503-668-5321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty