Provider Demographics
NPI:1427375724
Name:PERFORMANCE THERAPY, LLC
Entity Type:Organization
Organization Name:PERFORMANCE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:208-521-5691
Mailing Address - Street 1:1940 S BONITO WAY STE 190
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5618
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:
Practice Address - Street 1:3125 VALENCIA DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7575
Practice Address - Country:US
Practice Address - Phone:208-529-3332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-954225100000X
IDDME14657335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6448300001Medicare NSC
ID16532552Medicare PIN