MEDICARE: PROSPORTS REHAB

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0400X	Rehabilitation Clinic/Center	2027662	TX

General Provider Information

NPI Number	:	1316330707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROSPORTS REHAB

Provider Business Mailing Address
First Line	:	1111 SE MILITARY DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78214-2801
Country	:	US
Telephone Number	:	210-924-4475
Fax Number	:	210-924-9251

Provider Business Practice Location Address
First Line	:	1111 SE MILITARY DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78214-2801
Country	:	US
Telephone Number	:	210-924-4475
Fax Number	:	210-924-9251

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MR. LARRY WOOD
Credential	:	PT
Telephone Number	:	210-924-4475

Provider Enumeration Date	:	03/10/2015
Last Update Date	:	03/10/2015

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Directions to “PROSPORTS REHAB ” Practice Location

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