Basic Information
| Provider Information | |||||||||
| NPI: | 1750355996 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERFORMANCE THERAPEUTICS PLLC | ||||||||
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| OtherOrganizationName: | PERFORMANCE THERAPEUTICS PLLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2502 W FREDDY GONZALES DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785397387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563811600 | ||||||||
| FaxNumber: | 9563811616 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 LINDBERG AVE | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785012924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566874560 | ||||||||
| FaxNumber: | 9566181342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 01/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | PALOMIN | ||||||||
| AuthorizedOfficialFirstName: | OMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 9563811600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1139541 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 610717400 | 01 | TX | WORKERS COMPENSATION | OTHER | 0030KM | 01 | TX | BCBS | OTHER | 161271501 | 05 | TX | MEDICAID |