Healthcare Provider Details

I. General information

NPI: 1942641147
Provider Name (Legal Business Name): RET SUNRISE PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17528 MERIDIAN E STE 205
PUYALLUP WA
98375-6286
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 253-256-4807
  • Fax: 253-256-4809
Mailing address:
  • Phone: 813-560-8157
  • Fax: 425-452-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DWAN DIAZ
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 813-560-8157