Provider Demographics
NPI:1629241856
Name:PERFORMANCE BACK
Entity Type:Organization
Organization Name:PERFORMANCE BACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LEAHY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:719-473-7000
Mailing Address - Street 1:175 S UNION BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3113
Mailing Address - Country:US
Mailing Address - Phone:719-473-7478
Mailing Address - Fax:719-473-7479
Practice Address - Street 1:175 S UNION BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3113
Practice Address - Country:US
Practice Address - Phone:719-473-7478
Practice Address - Fax:719-473-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty