Provider Demographics
NPI:1295376689
Name:PERFORMANCE BOOST CENTER, LLC
Entity Type:Organization
Organization Name:PERFORMANCE BOOST CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-388-0700
Mailing Address - Street 1:1501 SUPERIOR AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3641
Mailing Address - Country:US
Mailing Address - Phone:949-612-7811
Mailing Address - Fax:848-612-7822
Practice Address - Street 1:1501 SUPERIOR AVE STE 304
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3641
Practice Address - Country:US
Practice Address - Phone:949-612-7811
Practice Address - Fax:848-612-7822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center