Provider Demographics
NPI:1588663975
Name:PERFORMANCE LIFESTYLES INC.
Entity Type:Organization
Organization Name:PERFORMANCE LIFESTYLES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRUNEAU
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:781-272-5151
Mailing Address - Street 1:23D CAMBRIDGE ST.
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-4601
Mailing Address - Country:US
Mailing Address - Phone:781-272-5151
Mailing Address - Fax:781-272-9992
Practice Address - Street 1:23D CAMBRIDGE ST.
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-4601
Practice Address - Country:US
Practice Address - Phone:781-272-5151
Practice Address - Fax:781-272-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPT0185Medicare ID - Type Unspecified