Provider Demographics
NPI:1275187650
Name:PHYSIOLETE THERAPY AND PERFORMANCE LLC
Entity Type:Organization
Organization Name:PHYSIOLETE THERAPY AND PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWTHORNE
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:205-292-2428
Mailing Address - Street 1:610 LURLEEN B WALLACE BLVD N
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 LURLEEN B WALLACE BLVD N
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-1713
Practice Address - Country:US
Practice Address - Phone:205-292-2428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy