Provider Demographics
NPI:1124438700
Name:SPORTS PRO PHYSICAL THERAPY SOUTH LLC
Entity type:Organization
Organization Name:SPORTS PRO PHYSICAL THERAPY SOUTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
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 1:930 E SWAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5250
Mailing Address - Country:US
Mailing Address - Phone:301-805-5006
Mailing Address - Fax:301-805-5004
Practice Address - Street 1:930 E SWAN CREEK RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5250
Practice Address - Country:US
Practice Address - Phone:301-805-5006
Practice Address - Fax:301-805-5004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPORTS PRO PHYSICAL THERAPY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty