Provider Demographics
NPI:1073097390
Name:PERFORMANCE PHYSIO PLLC
Entity Type:Organization
Organization Name:PERFORMANCE PHYSIO PLLC
Other - Org Name:PERFORMANCE HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-780-1090
Mailing Address - Street 1:621 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1871
Mailing Address - Country:US
Mailing Address - Phone:509-769-7551
Mailing Address - Fax:509-254-5018
Practice Address - Street 1:621 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1871
Practice Address - Country:US
Practice Address - Phone:509-769-7551
Practice Address - Fax:509-254-5018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-21
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy