Provider Demographics
NPI:1568509289
Name:PERFORMANCE PHYSICAL THERAPY PROF
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY PROF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TJADEN
Authorized Official - Suffix:
Authorized Official - Credentials:BS, ATC
Authorized Official - Phone:605-722-6880
Mailing Address - Street 1:215 E JACKSON BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-2176
Mailing Address - Country:US
Mailing Address - Phone:605-722-6880
Mailing Address - Fax:605-722-6889
Practice Address - Street 1:215 E JACKSON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-2176
Practice Address - Country:US
Practice Address - Phone:605-722-6880
Practice Address - Fax:605-722-6889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0041171OtherBLUE CROSS BLUE SHIELD SD
SD41872Medicare ID - Type UnspecifiedMEDICARE PART B