Provider Demographics
NPI:1508115056
Name:SPORTS AND BACK PT LLC
Entity Type:Organization
Organization Name:SPORTS AND BACK PT LLC
Other - Org Name:SPORTS AND BACK REHABILIATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-752-4553
Mailing Address - Street 1:370 E MAPLE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-2859
Mailing Address - Country:US
Mailing Address - Phone:215-752-4553
Mailing Address - Fax:215-752-0703
Practice Address - Street 1:370 E MAPLE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-2859
Practice Address - Country:US
Practice Address - Phone:215-752-4553
Practice Address - Fax:215-752-0703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy