Basic Information
| Provider Information | |||||||||
| NPI: | 1194282004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERFORMANCE PHYSICAL THERAPY OF NEW CANAAN, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PERFORMANCE PHYSICAL THERAPY AND WELLNESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 402 | ||||||||
| Address2: | |||||||||
| City: | COS COB | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068070402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035537626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16 CROSS ST | ||||||||
| Address2: | |||||||||
| City: | NEW CANAAN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068404831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034220679 | ||||||||
| FaxNumber: | 2036213162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2019 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | SIMONE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2035537626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.