Provider Demographics
NPI:1518492511
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HARRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-885-6371
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:
Practice Address - Street 1:6325 MULTIPLEX DR
Practice Address - Street 2:UNIT 2
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-5327
Practice Address - Country:US
Practice Address - Phone:571-932-3470
Practice Address - Fax:571-932-8075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty