Provider Demographics
NPI:1881770055
Name:SUN COUNTRY PHYSICAL THERAPY
Entity type:Organization
Organization Name:SUN COUNTRY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT MOMT
Authorized Official - Phone:505-625-9020
Mailing Address - Street 1:800 WEST SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201
Mailing Address - Country:US
Mailing Address - Phone:505-625-9020
Mailing Address - Fax:505-625-9025
Practice Address - Street 1:800 WEST SECOND STREET
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201
Practice Address - Country:US
Practice Address - Phone:505-625-9020
Practice Address - Fax:505-625-9025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB5672Medicaid