Provider Demographics
NPI:1902210644
Name:PERFORMANCE REHAB WELLNESS CENTER
Entity Type:Organization
Organization Name:PERFORMANCE REHAB WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HAZEL NIKKI
Authorized Official - Middle Name:MANGAOANG
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-490-4524
Mailing Address - Street 1:12389 SAN YSIDRO ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-6623
Mailing Address - Country:US
Mailing Address - Phone:760-490-4524
Mailing Address - Fax:760-927-3268
Practice Address - Street 1:12389 SAN YSIDRO ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-6623
Practice Address - Country:US
Practice Address - Phone:760-490-4524
Practice Address - Fax:760-927-3268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy