Basic Information
| Provider Information | |||||||||
| NPI: | 1366457095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARROLL SPORTS REHABILITATION AND PHYSICAL THERAPY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AGAPE PHYSICAL THERAPY AND SPORTS REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 179 | ||||||||
| Address2: | |||||||||
| City: | FOREST HILL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210500179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108386808 | ||||||||
| FaxNumber: | 4108382511 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 NEWPORT DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FOREST HILL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210501758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108389600 | ||||||||
| FaxNumber: | 4108388561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLGAIN | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4108386808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.