Provider Demographics
NPI:1740467463
Name:THERAPY PROVIDERS SERVICE ORGANIZATION, LLC
Entity type:Organization
Organization Name:THERAPY PROVIDERS SERVICE ORGANIZATION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:MASCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-723-3780
Mailing Address - Street 1:414 PENCO RD
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-3822
Mailing Address - Country:US
Mailing Address - Phone:304-723-3780
Mailing Address - Fax:304-723-4110
Practice Address - Street 1:47454 ROUTE 52
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:WV
Practice Address - Zip Code:25674-8052
Practice Address - Country:US
Practice Address - Phone:304-393-4072
Practice Address - Fax:304-393-4074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV002013370OtherMOUNTAIN STATE BCBS
WV3810011333Medicaid
WV002013370OtherMOUNTAIN STATE BCBS
WVDN0352Medicare PIN
WV=========OtherTAX ID #