Provider Demographics
NPI:1528041662
Name:PERSONAL PERFORMANCE MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PERSONAL PERFORMANCE MEDICAL CORPORATION
Other - Org Name:FIT-WELL PROSTHETIC & ORTHOTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PROSTHETIS
Authorized Official - Phone:801-364-3100
Mailing Address - Street 1:7575 S 900 E
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2343
Mailing Address - Country:US
Mailing Address - Phone:801-364-3100
Mailing Address - Fax:801-872-5714
Practice Address - Street 1:7575 S 900 E
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2343
Practice Address - Country:US
Practice Address - Phone:801-364-3100
Practice Address - Fax:801-872-5714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT19793280335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========003Medicaid
UT=========003Medicaid