Provider Demographics
NPI:1578787412
Name:THE PERFORMANCE PLACE PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:THE PERFORMANCE PLACE PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Other - Org Name:THE PERFORMANCE PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:HORACE
Authorized Official - Last Name:GIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:434-220-0805
Mailing Address - Street 1:1230 CEDARS CT STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-5800
Mailing Address - Country:US
Mailing Address - Phone:434-220-0805
Mailing Address - Fax:434-220-0806
Practice Address - Street 1:1230 CEDARS CT STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-5800
Practice Address - Country:US
Practice Address - Phone:434-220-0805
Practice Address - Fax:434-220-0806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23050039642251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08774Medicare ID - Type UnspecifiedGROUP NUMBER