Provider Demographics
NPI:1063784395
Name:SUNNYSIDE REHAB INC
Entity type:Organization
Organization Name:SUNNYSIDE REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LUDE
Authorized Official - Middle Name:REGINE
Authorized Official - Last Name:RICARD
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:619-621-9215
Mailing Address - Street 1:5703 OBERLIN DR STE 308
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1743
Mailing Address - Country:US
Mailing Address - Phone:619-621-9215
Mailing Address - Fax:866-666-7390
Practice Address - Street 1:5703 OBERLIN DR STE 308
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1743
Practice Address - Country:US
Practice Address - Phone:858-547-9101
Practice Address - Fax:866-666-7390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33814225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT33814OtherPT LICENSE NUMBER
CACS766ZMedicare UPIN