Provider Demographics
NPI:1649223694
Name:PROSPORT PHYSICAL THERAPY PROFESSIONALS INC
Entity Type:Organization
Organization Name:PROSPORT PHYSICAL THERAPY PROFESSIONALS INC
Other - Org Name:PROSPORT PHYSICAL THERAPY INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:ISMAIL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:209-353-1988
Mailing Address - Street 1:PO BOX 14155
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-1555
Mailing Address - Country:US
Mailing Address - Phone:714-450-4999
Mailing Address - Fax:714-974-0055
Practice Address - Street 1:2777 BRISTOL ST
Practice Address - Street 2:STE B
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5997
Practice Address - Country:US
Practice Address - Phone:949-250-1112
Practice Address - Fax:949-250-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14693Medicare UPIN