Basic Information
| Provider Information | |||||||||
| NPI: | 1225637861 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MVMT PERFORMANCE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 163 TABERNACLE RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD LAKES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080552024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562664910 | ||||||||
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| Practice Location | |||||||||
| Address1: | 133 EAYRESTOWN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHAMPTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080889122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562664910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2020 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | FILER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
| AuthorizedOfficialMiddleName: | TODD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6098453585 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT, ATC | ||||||||
| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.