Provider Demographics
NPI:1679520233
Name:PERFORMANCE PHYSICAL THERAPY OF SOUTH HOLLAND LLC
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY OF SOUTH HOLLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-979-2730
Mailing Address - Street 1:426 E 162ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2258
Mailing Address - Country:US
Mailing Address - Phone:708-333-0677
Mailing Address - Fax:708-333-1170
Practice Address - Street 1:426 E 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2258
Practice Address - Country:US
Practice Address - Phone:708-333-0677
Practice Address - Fax:708-333-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201407Medicare PIN