Provider Demographics
NPI:1912458621
Name:PRO PERFORM SPINAL HEALTH & REHAB LLC
Entity Type:Organization
Organization Name:PRO PERFORM SPINAL HEALTH & REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-705-7800
Mailing Address - Street 1:12070 OLD LINE CTR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2513
Mailing Address - Country:US
Mailing Address - Phone:301-705-7800
Mailing Address - Fax:301-705-7888
Practice Address - Street 1:6710 OXON HILL RD
Practice Address - Street 2:SUITE 400
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-1117
Practice Address - Country:US
Practice Address - Phone:301-705-7800
Practice Address - Fax:301-705-7888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS03581305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD371332Medicare PIN