Basic Information
| Provider Information | |||||||||
| NPI: | 1972675858 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORT & FAMILY PHYSICAL THERAPY, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 BREITEN CT | ||||||||
| Address2: | |||||||||
| City: | WOODBINE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217979205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107953289 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2470 LONGSTONE LANE | ||||||||
| Address2: | SUITE K | ||||||||
| City: | MARRIOTTSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104422470 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | TOROCKIO | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4105525632 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 17480 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.