Basic Information
| Provider Information | |||||||||
| NPI: | 1144687419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL SPORTSCARE & REHAB, LLC | ||||||||
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| OtherOrganizationName: | PIVOT PHYSICAL THERAPY OF METRO DC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7310 RITCHIE HWY | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210613065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107664047 | ||||||||
| FaxNumber: | 4107664049 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 SOLOMONS ISLAND RD N | ||||||||
| Address2: | |||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206783926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108854710 | ||||||||
| FaxNumber: | 4108854709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2016 | ||||||||
| LastUpdateDate: | 01/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | HARRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4108856371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.