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General NPI Number Information
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NPI Number | 1669700126
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Entity Type | Organization
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Legal Business Name | PRO SPORTS PERFORMANCE PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 11/20/2009
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Last Update Date | 11/20/2009
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Provider Practice Location Address
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Address Line | 190 BROADWAY
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City | GARDEN CITY PARK
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State | NY
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Zip | 11040-5333
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Country | US
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Telephone | 516-510-3713
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Fax | 516-246-2869
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Provider Business Mailing Address
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Address Line | 211 FERNWOOD TER
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City | STEWART MANOR
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State | NY
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Zip | 11530-5011
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Country | US
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Telephone | 516-510-3713
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Fax | 516-248-2869
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | WILLIAM GEORGE PETERS
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Credential | PT
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Telephone | 516-510-3713
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 029855
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License Number State | NY
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