MEDICARE: PRO SPORTS PERFORMANCE PHYSICAL THERAPY PC

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	261QP2000X	Physical Therapy Clinic/Center	029855	NY

General Provider Information

NPI Number	:	1669700126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO SPORTS PERFORMANCE PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	211 FERNWOOD TER
Second Line	:
City	:	STEWART MANOR
State	:	NY
Zip	:	11530-5011
Country	:	US
Telephone Number	:	516-510-3713
Fax Number	:	516-248-2869

Provider Business Practice Location Address
First Line	:	190 BROADWAY
Second Line	:
City	:	GARDEN CITY PARK
State	:	NY
Zip	:	11040-5333
Country	:	US
Telephone Number	:	516-510-3713
Fax Number	:	516-246-2869

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	WILLIAM GEORGE PETERS
Credential	:	PT
Telephone Number	:	516-510-3713

Provider Enumeration Date	:	11/20/2009
Last Update Date	:	11/20/2009

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