Provider Demographics
NPI:1679352884
Name:THE PERFORMANCE LAB
Entity Type:Organization
Organization Name:THE PERFORMANCE LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:475-233-3311
Mailing Address - Street 1:103 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1437
Mailing Address - Country:US
Mailing Address - Phone:203-232-5924
Mailing Address - Fax:
Practice Address - Street 1:40 UNION CITY RD STE D
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1585
Practice Address - Country:US
Practice Address - Phone:203-232-5924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty