Healthcare Provider Details

I. General information

NPI: 1649797747
Provider Name (Legal Business Name): PRO SPORTS THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4017 RAWLINS ST
CHEYENNE WY
82001-1800
US

IV. Provider business mailing address

4017 RAWLINS ST
CHEYENNE WY
82001-1800
US

V. Phone/Fax

Practice location:
  • Phone: 307-317-8332
  • Fax: 307-317-8337
Mailing address:
  • Phone: 307-317-8332
  • Fax: 307-317-8337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA J FOUNTAIN
Title or Position: OWNER
Credential:
Phone: 307-317-8332