Provider Demographics
NPI:1659638567
Name:PEAK PERFORMANCE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:PEAK PERFORMANCE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PELLEGRINO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, CSCS
Authorized Official - Phone:617-828-5617
Mailing Address - Street 1:965 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-4510
Mailing Address - Country:US
Mailing Address - Phone:617-828-5617
Mailing Address - Fax:
Practice Address - Street 1:965 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4510
Practice Address - Country:US
Practice Address - Phone:617-828-5617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
97063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty