Healthcare Provider Details

I. General information

NPI: 1912129743
Provider Name (Legal Business Name): SPORT & SPINE REHAB OF FORT WASHINGTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11418 LIVINGSTON RD
FT WASHINGTON MD
20744-5145
US

IV. Provider business mailing address

11418 LIVINGSTON RD
FT WASHINGTON MD
20744-5145
US

V. Phone/Fax

Practice location:
  • Phone: 240-766-0300
  • Fax: 240-766-0304
Mailing address:
  • Phone: 240-766-0300
  • Fax: 240-766-0304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. JAY S GREENSTEIN
Title or Position: CEO
Credential: DC
Phone: 240-766-0300