Provider Demographics
NPI:1851427132
Name:PERFORMANCE THERAPY LLC
Entity Type:Organization
Organization Name:PERFORMANCE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:II
Authorized Official - Credentials:PT
Authorized Official - Phone:601-650-0002
Mailing Address - Street 1:PERFORMANCE THERAPY, LLC
Mailing Address - Street 2:921 W BEACON STREET
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350
Mailing Address - Country:US
Mailing Address - Phone:601-650-0002
Mailing Address - Fax:601-650-9902
Practice Address - Street 1:PERFORMANCE THERAPY, LLC
Practice Address - Street 2:921 W BEACON STREET
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350
Practice Address - Country:US
Practice Address - Phone:601-650-0002
Practice Address - Fax:601-650-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03186Medicare ID - Type UnspecifiedGROUP NUMBER