Provider Demographics
NPI:1942641147
Name:RET SUNRISE PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:RET SUNRISE PHYSICAL THERAPY, PLLC
Other - Org Name:RET SUNRISE PHYSICAL THERAPY PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-560-8157
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:813-560-8157
Mailing Address - Fax:425-452-0704
Practice Address - Street 1:17528 MERIDIAN E STE 205
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-6286
Practice Address - Country:US
Practice Address - Phone:253-256-4807
Practice Address - Fax:253-256-4809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty