Provider Demographics
NPI:1578589131
Name:SUNNYSIDE PHYSICAL & SPORTS THERAPY
Entity type:Organization
Organization Name:SUNNYSIDE PHYSICAL & SPORTS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARNINE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-531-5918
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0090
Mailing Address - Country:US
Mailing Address - Phone:509-837-7400
Mailing Address - Fax:509-837-5068
Practice Address - Street 1:1405 E EDISON AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-1622
Practice Address - Country:US
Practice Address - Phone:509-837-7400
Practice Address - Fax:509-837-5068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009405225100000X
WAMA00017601225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8854790Medicare PIN