Provider Demographics
NPI:1437307485
Name:PERFORMANCE EDGE SPORTS, LLC
Entity Type:Organization
Organization Name:PERFORMANCE EDGE SPORTS, LLC
Other - Org Name:FAMILY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TODT
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, CSCS
Authorized Official - Phone:860-917-6536
Mailing Address - Street 1:7 PARK AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1128
Mailing Address - Country:US
Mailing Address - Phone:860-531-3222
Mailing Address - Fax:860-531-3224
Practice Address - Street 1:7 PARK AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1128
Practice Address - Country:US
Practice Address - Phone:860-531-3222
Practice Address - Fax:860-531-3224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty