Provider Demographics
NPI:1215598529
Name:PRO PERFORMANCE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PRO PERFORMANCE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-565-7950
Mailing Address - Street 1:2544 E SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3228
Mailing Address - Country:US
Mailing Address - Phone:954-253-0863
Mailing Address - Fax:954-416-3625
Practice Address - Street 1:2544 E SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3228
Practice Address - Country:US
Practice Address - Phone:954-253-0863
Practice Address - Fax:954-416-3625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty