Provider Demographics
NPI:1316330707
Name:PROSPORTS REHAB
Entity type:Organization
Organization Name:PROSPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:210-924-4475
Mailing Address - Street 1:1111 SE MILITARY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-2801
Mailing Address - Country:US
Mailing Address - Phone:210-924-4475
Mailing Address - Fax:210-924-9251
Practice Address - Street 1:1111 SE MILITARY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214-2801
Practice Address - Country:US
Practice Address - Phone:210-924-4475
Practice Address - Fax:210-924-9251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2027662261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation