Basic Information
| Provider Information | |||||||||
| NPI: | 1093954158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCE PHYSICAL THERAPY & SPORTS REHAB. INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3411 OLANDWOOD CT | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2407509966 | ||||||||
| FaxNumber: | 3017741336 | ||||||||
| Practice Location | |||||||||
| Address1: | 3411 OLANDWOOD CT | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2407509966 | ||||||||
| FaxNumber: | 3017741336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2009 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | RUTA | ||||||||
| AuthorizedOfficialFirstName: | MARIAN | ||||||||
| AuthorizedOfficialMiddleName: | CUBA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3015703588 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | D.P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 18214 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 355103200 | 05 | MD | MEDICAID |