Provider Demographics
NPI:1487648341
Name:PROSPORT PHYSICAL THERAPY PROFESSIONALS INC
Entity type:Organization
Organization Name:PROSPORT PHYSICAL THERAPY PROFESSIONALS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:ISMAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-353-1988
Mailing Address - Street 1:PO BOX 14155
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-1555
Mailing Address - Country:US
Mailing Address - Phone:714-450-4999
Mailing Address - Fax:714-974-0055
Practice Address - Street 1:28924 S WESTERN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-0885
Practice Address - Country:US
Practice Address - Phone:310-548-0104
Practice Address - Fax:310-548-0559
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALOS VERDES REHABILITATION CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-07
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14553Medicare ID - Type UnspecifiedGROUP ID #