Basic Information
| Provider Information | |||||||||
| NPI: | 1518492511 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL SPORTSCARE & REHAB, LLC | ||||||||
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| OtherOrganizationName: | PIVOT PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 FAIRMOUNT AVE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109278768 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6325 MULTIPLEX DR | ||||||||
| Address2: | UNIT 2 | ||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201215327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5719323470 | ||||||||
| FaxNumber: | 5719328075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2017 | ||||||||
| LastUpdateDate: | 04/27/2017 | ||||||||
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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 | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.