Basic Information
| Provider Information | |||||||||
| NPI: | 1245979616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL SPORTSCARE & REHAB OF WEST VIRGINIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 NEW FIDELITY COURT | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193732919 | ||||||||
| FaxNumber: | 4106484868 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 RETAIL COMMONS PKWY | ||||||||
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| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254036182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193732919 | ||||||||
| FaxNumber: | 4106484868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2022 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | HUDSON | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9195784538 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PESC | ||||||||
| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.