Provider Demographics
NPI:1881069789
Name:SPORTPRO LLC
Entity type:Organization
Organization Name:SPORTPRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLING
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:815-546-8865
Mailing Address - Street 1:781 FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-1165
Mailing Address - Country:US
Mailing Address - Phone:740-263-7997
Mailing Address - Fax:740-326-4743
Practice Address - Street 1:781 FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1165
Practice Address - Country:US
Practice Address - Phone:740-263-7997
Practice Address - Fax:740-326-4743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT013341261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy