Provider Demographics
NPI:1598802423
Name:PROGRESSIVE SPINAL AND SPORTS REHABILITATION, PC
Entity Type:Organization
Organization Name:PROGRESSIVE SPINAL AND SPORTS REHABILITATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:240-477-8719
Mailing Address - Street 1:15200 SHADY GROVE RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3218
Mailing Address - Country:US
Mailing Address - Phone:240-477-8719
Mailing Address - Fax:
Practice Address - Street 1:15200 SHADY GROVE RD
Practice Address - Street 2:SUITE 211
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3218
Practice Address - Country:US
Practice Address - Phone:240-477-8719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02093111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty