Provider Demographics
NPI:1407397896
Name:PROFESSIONAL SPORTSCARE & REHAB, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL SPORTSCARE & REHAB, LLC
Other - Org Name:PIVOT PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TASHEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:PESC
Authorized Official - Phone:252-248-3313
Mailing Address - Street 1:501 FAIRMOUNT AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5457
Mailing Address - Country:US
Mailing Address - Phone:410-927-8768
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:2875 CRAIN HWY
Practice Address - Street 2:STE 6
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2807
Practice Address - Country:US
Practice Address - Phone:301-859-3304
Practice Address - Fax:301-383-8305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-17
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty