Provider Demographics
NPI:1376763722
Name:PERFORMANCE PHYSICAL THERAPY & SPORTS CONDITIONING LLC
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY & SPORTS CONDITIONING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPLES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, ATC
Authorized Official - Phone:201-286-0585
Mailing Address - Street 1:2025 HAMBURG TPKE STE E
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-6250
Mailing Address - Country:US
Mailing Address - Phone:973-835-2827
Mailing Address - Fax:973-835-1856
Practice Address - Street 1:2025 HAMBURG TPKE STE E
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-6250
Practice Address - Country:US
Practice Address - Phone:973-835-2827
Practice Address - Fax:973-835-1856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01180900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty