Provider Demographics
NPI:1760815559
Name:PERFORMANCE PHYSICAL THERAPY & WELLNESS LLC
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROERING
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:567-644-9073
Mailing Address - Street 1:216 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:OH
Mailing Address - Zip Code:45828-1703
Mailing Address - Country:US
Mailing Address - Phone:419-763-1464
Mailing Address - Fax:419-763-1482
Practice Address - Street 1:216 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:OH
Practice Address - Zip Code:45828-1703
Practice Address - Country:US
Practice Address - Phone:419-763-1464
Practice Address - Fax:419-763-1482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11545225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty