Provider Demographics
NPI:1295860765
Name:PEAK PERFORMANCE PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:PEAK PERFORMANCE PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HATHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:607-687-7645
Mailing Address - Street 1:115 HICKORIES PARK RD
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-4845
Mailing Address - Country:US
Mailing Address - Phone:607-687-7645
Mailing Address - Fax:607-687-7646
Practice Address - Street 1:115 HICKORIES PARK RD
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-4845
Practice Address - Country:US
Practice Address - Phone:607-687-7645
Practice Address - Fax:607-687-7646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011651-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC2811Medicare ID - Type UnspecifiedBRYAN D HATHAWAY