Provider Demographics
NPI:1629095344
Name:PERFORMANCE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:JON
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:530-842-5220
Mailing Address - Street 1:1289 S MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3433
Mailing Address - Country:US
Mailing Address - Phone:530-842-5220
Mailing Address - Fax:530-842-5210
Practice Address - Street 1:1289 S MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3433
Practice Address - Country:US
Practice Address - Phone:530-842-5220
Practice Address - Fax:530-842-5210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 22955225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT229550Medicare ID - Type UnspecifiedOUTPATIENT PT CLINIC