Provider Demographics
NPI:1083651673
Name:SUNRISE PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:SUNRISE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:KONDRA
Authorized Official - Last Name:SILLS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:802-644-8011
Mailing Address - Street 1:44 LAMOILLE VIEW LN
Mailing Address - Street 2:P.O. BOX 103
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05464-4427
Mailing Address - Country:US
Mailing Address - Phone:802-644-8011
Mailing Address - Fax:802-644-8047
Practice Address - Street 1:44 LAMOILLE VIEW LN
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05464-4427
Practice Address - Country:US
Practice Address - Phone:802-644-8011
Practice Address - Fax:802-644-8047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400002460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN3053Medicaid
VTOVN3053Medicaid