Provider Demographics
NPI:1720562069
Name:PROFORMANCE SPORTS REHABILITATION
Entity Type:Organization
Organization Name:PROFORMANCE SPORTS REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDEN
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:860-917-7610
Mailing Address - Street 1:2637 STREAMVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1579
Mailing Address - Country:US
Mailing Address - Phone:860-917-7610
Mailing Address - Fax:
Practice Address - Street 1:2637 STREAMVIEW DR
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1579
Practice Address - Country:US
Practice Address - Phone:860-917-7610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-22
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty