MEDICARE: PROFESSIONAL SPORTSCARE & REHAB OF WEST VIRGINIA, LLC

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1780134353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL SPORTSCARE & REHAB OF WEST VIRGINIA, LLC

Provider Business Mailing Address
First Line	:	2122 YORK RD STE 302
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1930
Country	:	US
Telephone Number	:	410-927-8768
Fax Number	:

Provider Business Practice Location Address
First Line	:	39 MADDEX DR
Second Line	:	STE 2
City	:	SHEPHERDSTOWN
State	:	WV
Zip	:	25443-4322
Country	:	US
Telephone Number	:	304-876-8600
Fax Number	:

Authorized Official
Title or Position	:	MANAGER, CREDENTIALING
Name	:	TASHEDA BROUGHTON
Credential	:	PESC
Telephone Number	:	252-248-3313

Provider Enumeration Date	:	10/07/2016
Last Update Date	:	11/01/2024

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