Provider Demographics
NPI:1285925453
Name:SUNDOG REHABILITATION LLC
Entity type:Organization
Organization Name:SUNDOG REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTYJOHN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:605-787-2719
Mailing Address - Street 1:3064 COVINGTON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-7207
Mailing Address - Country:US
Mailing Address - Phone:605-787-2719
Mailing Address - Fax:605-718-4452
Practice Address - Street 1:3064 COVINGTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57703-7207
Practice Address - Country:US
Practice Address - Phone:605-787-2719
Practice Address - Fax:605-718-4452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1487261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
S105011OtherMEDICARE PTAN