Provider Demographics
NPI:1376937896
Name:SPORTSMED OF GLEN ROCK PA
Entity Type:Organization
Organization Name:SPORTSMED OF GLEN ROCK PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-803-7695
Mailing Address - Street 1:266 HARRISTOWN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3302
Mailing Address - Country:US
Mailing Address - Phone:201-803-7695
Mailing Address - Fax:
Practice Address - Street 1:266 HARRISTOWN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-3302
Practice Address - Country:US
Practice Address - Phone:201-803-7695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty