=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013467976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL SPORTSCARE & REHAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2016
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6530 TRADING SQ
-----------------------------------------------------
City | HAYMARKET
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20169-2278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-932-3480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2122 YORK RD STE 300
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-248-3313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER, CREDENTIALING
-----------------------------------------------------
Name | TASHEDA BROUGHTON
-----------------------------------------------------
Credential | PESC
-----------------------------------------------------
Telephone | 252-248-3313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------