Basic Information
| Provider Information | |||||||||
| NPI: | 1851427132 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERFORMANCE THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PERFORMANCE THERAPY, LLC | ||||||||
| Address2: | 921 W BEACON STREET | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016500002 | ||||||||
| FaxNumber: | 6016509902 | ||||||||
| Practice Location | |||||||||
| Address1: | PERFORMANCE THERAPY, LLC | ||||||||
| Address2: | 921 W BEACON STREET | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016500002 | ||||||||
| FaxNumber: | 6016509902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6016500002 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT2372 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.