Provider Demographics
NPI:1548404577
Name:PROFESSIONAL SPORTSCARE & REHAB OF WEST VIRGINIA, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL SPORTSCARE & REHAB OF WEST VIRGINIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DRCM
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-225-4492
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:304-876-8601
Practice Address - Street 1:207 S PRINCESS ST STE 3AND4
Practice Address - Street 2:
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-1581
Practice Address - Country:US
Practice Address - Phone:304-876-8600
Practice Address - Fax:304-876-8601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT 002689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty