Provider Demographics
NPI:1508392515
Name:PREMIER PERFORMANCE PHYSICAL THERAPY AND SPORTS MEDICINE, L.L.C.
Entity Type:Organization
Organization Name:PREMIER PERFORMANCE PHYSICAL THERAPY AND SPORTS MEDICINE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, PT
Authorized Official - Phone:978-500-3003
Mailing Address - Street 1:431 TRAPELO RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-1417
Mailing Address - Country:US
Mailing Address - Phone:617-932-1027
Mailing Address - Fax:617-932-1476
Practice Address - Street 1:431 TRAPELO RD UNIT 2
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-1417
Practice Address - Country:US
Practice Address - Phone:617-932-1027
Practice Address - Fax:317-932-1476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20432261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy