1942641147 NPI number — RET SUNRISE PHYSICAL THERAPY, PLLC

Table of content: (NPI 1942641147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942641147 NPI number — RET SUNRISE PHYSICAL THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RET SUNRISE PHYSICAL THERAPY, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RET SUNRISE PHYSICAL THERAPY PLLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942641147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 LYNDON FARM CT STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40223-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-560-8157
Provider Business Mailing Address Fax Number:
425-452-0704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17528 MERIDIAN E STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98375-6286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-256-4807
Provider Business Practice Location Address Fax Number:
253-256-4809
Provider Enumeration Date:
07/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DIAZ
Authorized Official First Name:
DWAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
813-560-8157

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225XH1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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