Basic Information
| Provider Information | |||||||||
| NPI: | 1982750931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN DELAWARE SPORTS CARE AND REHABILITATION, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROFESSIONAL PHYSICAL THERAPY AND SPORTS CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28577 MARYS CT | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216017499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108854970 | ||||||||
| FaxNumber: | 4108854669 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 MIDDLEFORD RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SEAFORD | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199733670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026295700 | ||||||||
| FaxNumber: | 3026296001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 08/13/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YOVIENE | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4108295647 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | P.T. | ||||||||
| NPICertificationDate: | |||||||||
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 |
ID Information
| ID | Type | State | Issuer | Description | 1000023483 | 05 | DE | MEDICAID | K752 | 01 | DC | BLUECHOICE | OTHER | 568A | 01 | MD | CAREFIRST | OTHER |