Provider Demographics
NPI:1821721507
Name:PERFORM PHYSICAL THERAPY AND WELLNESS
Entity Type:Organization
Organization Name:PERFORM PHYSICAL THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:CLAIRE
Authorized Official - Last Name:HAEUPTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:609-851-7719
Mailing Address - Street 1:353 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6663 EL CAJON BLVD STE E
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-2850
Practice Address - Country:US
Practice Address - Phone:858-208-0465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy