Provider Demographics
NPI:1083259139
Name:VIVID PERFORMANCE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:VIVID PERFORMANCE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT,OCS,CSCS
Authorized Official - Phone:269-377-5117
Mailing Address - Street 1:1517 15TH STREET
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1517 15TH STREET
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76226
Practice Address - Country:US
Practice Address - Phone:269-377-5117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty