Provider Demographics
NPI:1790952273
Name:PERFORMANCE PHYSICAL THERAPY & SPORTS MEDICINE INC
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY & SPORTS MEDICINE INC
Other - Org Name:PERFORMANCE PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER LPT THERAPIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:MEEKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:936-321-1101
Mailing Address - Street 1:PO BOX 3064
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77305-3064
Mailing Address - Country:US
Mailing Address - Phone:936-321-1101
Mailing Address - Fax:936-321-1107
Practice Address - Street 1:18445 HIGHWAY 105 W
Practice Address - Street 2:SUITE 103
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-6064
Practice Address - Country:US
Practice Address - Phone:936-321-1101
Practice Address - Fax:936-321-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1143378225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1417997826OtherINDIVIDUAL NPI #
TX0078223OtherBLUE LINK #
TX8T6301OtherINDIVIDUAL BC/BS PROVIDER #