Provider Demographics
NPI:1346998978
Name:SPORTS PRO PHYSICAL THERAPY EAST
Entity Type:Organization
Organization Name:SPORTS PRO PHYSICAL THERAPY EAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:301-805-5006
Mailing Address - Street 1:626 ADMIRAL DR STE D
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-2151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:626 ADMIRAL DR STE D
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-2151
Practice Address - Country:US
Practice Address - Phone:301-805-5006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPORTS PRO PHYSICAL THERAPY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty