Provider Demographics
NPI:1235366055
Name:PRO SPORTS PERFORMANCE, INC
Entity Type:Organization
Organization Name:PRO SPORTS PERFORMANCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:516-510-3713
Mailing Address - Street 1:211 FERNWOOD TER
Mailing Address - Street 2:
Mailing Address - City:STEWART MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5011
Mailing Address - Country:US
Mailing Address - Phone:516-510-3713
Mailing Address - Fax:516-248-2869
Practice Address - Street 1:190 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARDEN CITY PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-5333
Practice Address - Country:US
Practice Address - Phone:516-510-3713
Practice Address - Fax:516-248-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029855-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy