Provider Demographics
NPI:1962988386
Name:OPTIMAL PHYSICAL THERAPY SPORTS AND WELLNESS CENTER,LLC
Entity type:Organization
Organization Name:OPTIMAL PHYSICAL THERAPY SPORTS AND WELLNESS CENTER,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:VALENTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KORETSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-251-9081
Mailing Address - Street 1:15245 SHADY GROVE RD STE 475
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3222
Mailing Address - Country:US
Mailing Address - Phone:240-474-5185
Mailing Address - Fax:
Practice Address - Street 1:15245 SHADY GROVE RD STE 475
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3222
Practice Address - Country:US
Practice Address - Phone:240-474-5185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty