Healthcare Provider Details

I. General information

NPI: 1366457095
Provider Name (Legal Business Name): CARROLL SPORTS REHABILITATION AND PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 NEWPORT DR SUITE A
FOREST HILL MD
21050-1758
US

IV. Provider business mailing address

PO BOX 179
FOREST HILL MD
21050-0179
US

V. Phone/Fax

Practice location:
  • Phone: 410-838-9600
  • Fax: 410-838-8561
Mailing address:
  • Phone: 410-838-6808
  • Fax: 410-838-2511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMD

VIII. Authorized Official

Name: MR. JOSEPH COLGAIN
Title or Position: DIRECTOR
Credential: PT
Phone: 410-838-6808