Provider Demographics
NPI:1700835808
Name:PERFORMANCE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF BUSINESS AFFAIRS
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-922-9508
Mailing Address - Street 1:9711 VALPARAISO DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2866
Mailing Address - Country:US
Mailing Address - Phone:219-922-9508
Mailing Address - Fax:219-924-4978
Practice Address - Street 1:5100 S CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8976
Practice Address - Country:US
Practice Address - Phone:386-304-8112
Practice Address - Fax:386-304-8014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22239225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4417Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER