Provider Demographics
NPI:1336468891
Name:PERFORMANCE WELLNESS PHYSICAL THERAPY CENTER
Entity Type:Organization
Organization Name:PERFORMANCE WELLNESS PHYSICAL THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:512-491-7772
Mailing Address - Street 1:6500 N MOPAC EXPY
Mailing Address - Street 2:BLDG. 3, STE. 101
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3282
Mailing Address - Country:US
Mailing Address - Phone:512-491-7772
Mailing Address - Fax:512-339-6806
Practice Address - Street 1:6500 N MOPAC EXPY
Practice Address - Street 2:BLDG. 3, STE. 101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3282
Practice Address - Country:US
Practice Address - Phone:512-491-7772
Practice Address - Fax:512-339-6806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty