Provider Demographics
NPI:1043429384
Name:SPORTSPROS, INC.
Entity Type:Organization
Organization Name:SPORTSPROS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:
Authorized Official - Last Name:ESCALANTE
Authorized Official - Suffix:
Authorized Official - Credentials:DSC, MBA, ATC, CSCS
Authorized Official - Phone:909-447-5724
Mailing Address - Street 1:928 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3303
Mailing Address - Country:US
Mailing Address - Phone:909-447-5724
Mailing Address - Fax:909-447-5734
Practice Address - Street 1:928 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3303
Practice Address - Country:US
Practice Address - Phone:909-447-5724
Practice Address - Fax:909-447-5734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25345225100000X
CA32957225100000X
CAAT9150225200000X
CA0898024332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18241Medicare UPIN