Provider Demographics
NPI:1619680105
Name:POSITIVE PERFORMANCE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:POSITIVE PERFORMANCE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:814-441-9183
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:BOALSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16827-0218
Mailing Address - Country:US
Mailing Address - Phone:814-441-9183
Mailing Address - Fax:833-277-6195
Practice Address - Street 1:1146 KAREN ST
Practice Address - Street 2:
Practice Address - City:BOALSBURG
Practice Address - State:PA
Practice Address - Zip Code:16827-1642
Practice Address - Country:US
Practice Address - Phone:814-441-9183
Practice Address - Fax:833-277-6195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101115561-0005Medicaid