Provider Demographics
NPI:1265029128
Name:PHYSIOSPORT: PERFORMANCE AND PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:PHYSIOSPORT: PERFORMANCE AND PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAHMOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:209-481-7336
Mailing Address - Street 1:4929 FRANCO AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-1909
Mailing Address - Country:US
Mailing Address - Phone:209-481-7336
Mailing Address - Fax:
Practice Address - Street 1:4929 FRANCO AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-1909
Practice Address - Country:US
Practice Address - Phone:209-481-7336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-27
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies