Provider Demographics
NPI:1417427345
Name:PERFORM FOR LIFE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PERFORM FOR LIFE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-991-6978
Mailing Address - Street 1:537 BALTIMORE ANNAPOLIS BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-3812
Mailing Address - Country:US
Mailing Address - Phone:410-544-8444
Mailing Address - Fax:410-544-7941
Practice Address - Street 1:537 BALTIMORE ANNAPOLIS BLVD STE D
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-3812
Practice Address - Country:US
Practice Address - Phone:410-544-8444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-04
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
T2080134OtherBLUECROSS BLUESHIELD