Provider Demographics
NPI:1639229115
Name:SUN VALLEY SPORTS REHABILITATION
Entity Type:Organization
Organization Name:SUN VALLEY SPORTS REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:COYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-726-7246
Mailing Address - Street 1:PO BOX 2062
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-2062
Mailing Address - Country:US
Mailing Address - Phone:208-726-7246
Mailing Address - Fax:208-726-8911
Practice Address - Street 1:245 RAVEN RD
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-726-7246
Practice Address - Fax:208-726-8911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3322251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1650889Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER