Basic Information
| Provider Information | |||||||||
| NPI: | 1669481222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERFORMANCE GROUP ALBERTVILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 14149 | ||||||||
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| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708984149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2259249827 | ||||||||
| FaxNumber: | 2259249829 | ||||||||
| Practice Location | |||||||||
| Address1: | 4198 U.S. HWY. 431 | ||||||||
| Address2: | STE D | ||||||||
| City: | ALBERTVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359510238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568943870 | ||||||||
| FaxNumber: | 2568943872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 08/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2567443350 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.