Provider Demographics
NPI:1417115049
Name:PENINSULA REHABILITATION AND SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:PENINSULA REHABILITATION AND SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MED, PT, ATC
Authorized Official - Phone:302-645-9797
Mailing Address - Street 1:18958 COASTAL HWY STE A
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-6196
Mailing Address - Country:US
Mailing Address - Phone:302-645-9797
Mailing Address - Fax:302-645-0411
Practice Address - Street 1:18958 COASTAL HWY STE A
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-6196
Practice Address - Country:US
Practice Address - Phone:302-645-9797
Practice Address - Fax:302-645-0411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0000810225100000X
DEJ1-0002288225100000X
DEJ1-0001325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty