Provider Demographics
NPI:1366457095
Name:CARROLL SPORTS REHABILITATION AND PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:CARROLL SPORTS REHABILITATION AND PHYSICAL THERAPY, LLC
Other - Org Name:AGAPE PHYSICAL THERAPY AND SPORTS REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:COLGAIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-838-6808
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-0179
Mailing Address - Country:US
Mailing Address - Phone:410-838-6808
Mailing Address - Fax:410-838-2511
Practice Address - Street 1:12 NEWPORT DR
Practice Address - Street 2:SUITE A
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-1758
Practice Address - Country:US
Practice Address - Phone:410-838-9600
Practice Address - Fax:410-838-8561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR11985Medicare UPIN