Provider Demographics
NPI:1437936192
Name:PTSPORTSPRO, PLLC
Entity Type:Organization
Organization Name:PTSPORTSPRO, PLLC
Other - Org Name:PTSPORTSPRO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:RODERICK
Authorized Official - Last Name:REUBEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:616-901-3831
Mailing Address - Street 1:1925 BRETON RD SE STE 130
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4810
Mailing Address - Country:US
Mailing Address - Phone:866-478-7776
Mailing Address - Fax:
Practice Address - Street 1:1925 BRETON RD SE STE 130
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4810
Practice Address - Country:US
Practice Address - Phone:616-901-3831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-14
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty