Provider Demographics
NPI:1407564024
Name:SOUVA PT AND PERFORMANCE
Entity Type:Organization
Organization Name:SOUVA PT AND PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:BRAD
Authorized Official - Last Name:SOUVA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:586-569-1621
Mailing Address - Street 1:71575 JULIUS DR
Mailing Address - Street 2:
Mailing Address - City:BRUCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48065-3187
Mailing Address - Country:US
Mailing Address - Phone:586-569-1621
Mailing Address - Fax:
Practice Address - Street 1:2615 NAKOTA RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1816
Practice Address - Country:US
Practice Address - Phone:586-210-0530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy