MEDICARE: PROVEN PHYSICAL THERAPY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1750956389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVEN PHYSICAL THERAPY INC

Provider Business Mailing Address
First Line	:	3410 MANDERES PL
Second Line	:
City	:	SPRINGDALE
State	:	MD
Zip	:	20774-2526
Country	:	US
Telephone Number	:	240-899-2251
Fax Number	:

Provider Business Practice Location Address
First Line	:	3410 MANDERES PL
Second Line	:
City	:	SPRINGDALE
State	:	MD
Zip	:	20774-2526
Country	:	US
Telephone Number	:	240-899-2251
Fax Number	:

Authorized Official
Title or Position	:	CEO/PHYSICAL THERAPIST
Name	:	MR. OLAYINKA GBENGA FOLAYAN
Credential	:
Telephone Number	:	240-899-2251

Provider Enumeration Date	:	05/25/2021
Last Update Date	:	05/25/2021

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