Provider Demographics
NPI:1932576378
Name:SPORTS PRO PHYSICAL THERAPY LLC.
Entity Type:Organization
Organization Name:SPORTS PRO PHYSICAL THERAPY LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:301-805-5006
Mailing Address - Street 1:12200 ANNAPOLIS RD
Mailing Address - Street 2:#119
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9182
Mailing Address - Country:US
Mailing Address - Phone:301-805-5006
Mailing Address - Fax:301-805-5004
Practice Address - Street 1:12200 ANNAPOLIS RD
Practice Address - Street 2:#119
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9182
Practice Address - Country:US
Practice Address - Phone:301-805-5006
Practice Address - Fax:301-805-5004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty