Provider Demographics
NPI:1164044590
Name:PRESTIGE HEALTH & PERFORMANCE
Entity Type:Organization
Organization Name:PRESTIGE HEALTH & PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:DWAGNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:404-668-9560
Mailing Address - Street 1:20354 CHESTNUT GROVE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20354 CHESTNUT GROVE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3344
Practice Address - Country:US
Practice Address - Phone:404-668-9560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty