Provider Demographics
NPI:1114154622
Name:PERSONAL PERFORMANCE MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PERSONAL PERFORMANCE MEDICAL CORPORATION
Other - Org Name:FIT-WELL PROSTHETIC AND ORTHOTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PROSTHETIS
Authorized Official - Phone:801-364-3100
Mailing Address - Street 1:50 S 900 E STE 1
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1366
Mailing Address - Country:US
Mailing Address - Phone:801-364-3100
Mailing Address - Fax:801-575-5462
Practice Address - Street 1:3354 HARRISON BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1296
Practice Address - Country:US
Practice Address - Phone:801-334-6000
Practice Address - Fax:801-317-4019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERSONAL PERFORMANCE MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-11
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier