Provider Demographics
NPI:1114257383
Name:PHYSICAL RESTORATION AND SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:PHYSICAL RESTORATION AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:O
Authorized Official - Last Name:MEADOWS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:703-444-8210
Mailing Address - Street 1:46304 MCCLELLAN WAY
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-7243
Mailing Address - Country:US
Mailing Address - Phone:703-444-8210
Mailing Address - Fax:703-444-8213
Practice Address - Street 1:46304 MCCLELLAN WAY
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-7243
Practice Address - Country:US
Practice Address - Phone:703-444-8210
Practice Address - Fax:703-444-8213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty