Provider Demographics
NPI:1003011537
Name:PEAK PERFORMANCE THERAPY LLC
Entity Type:Organization
Organization Name:PEAK PERFORMANCE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KEENAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:804-758-5588
Mailing Address - Street 1:390 VIRGINIA ST
Mailing Address - Street 2:B
Mailing Address - City:URBANNA
Mailing Address - State:VA
Mailing Address - Zip Code:23175
Mailing Address - Country:US
Mailing Address - Phone:804-758-5588
Mailing Address - Fax:804-758-5589
Practice Address - Street 1:390 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:URBANNA
Practice Address - State:VA
Practice Address - Zip Code:23175
Practice Address - Country:US
Practice Address - Phone:804-758-5588
Practice Address - Fax:804-758-5589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003508225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA364394OtherANTHEM
VA1003011537Medicaid
C10266Medicare PIN