Basic Information
| Provider Information | |||||||||
| NPI: | 1811347818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERFORMANCE THERAPEUTICS - SAN ANTONIO PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 N 23RD ST | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785016127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566874560 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7220 LOUIS PASTEUR DR STE 144 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566874560 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2016 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | PALOMIN | ||||||||
| AuthorizedOfficialFirstName: | OMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9566874560 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 08/24/2022 | ||||||||
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 |
ID Information
| ID | Type | State | Issuer | Description | 680380000 | 01 | TX | FACILITY LICENSE | OTHER |