Healthcare Provider Details

I. General information

NPI: 1205213923
Provider Name (Legal Business Name): PENINSULA REGIONAL REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 WOODBROOKE DR SUITE 102
SALISBURY MD
21804-2317
US

IV. Provider business mailing address

20410 CENTURY BLVD SUITE 215
GERMANTOWN MD
20874-1186
US

V. Phone/Fax

Practice location:
  • Phone: 301-540-6140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOHN BRICKLEY
Title or Position: VICE PRESIDENT AMBULATORY OPERATION
Credential:
Phone: 301-540-6140