Provider Demographics
NPI:1962511949
Name:PERFORMANCE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARRIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:480-756-8617
Mailing Address - Street 1:8725 S KYRENE RD
Mailing Address - Street 2:STE 106
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-2116
Mailing Address - Country:US
Mailing Address - Phone:480-756-8617
Mailing Address - Fax:480-820-9909
Practice Address - Street 1:8725 S KYRENE RD
Practice Address - Street 2:STE 106
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-2116
Practice Address - Country:US
Practice Address - Phone:480-756-8617
Practice Address - Fax:480-820-9909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5457225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2Z2989OtherHEALTHNET
AZ318389OtherARIZONA HEALTHCARE COST CONTAINMENT SYSTEM (AHCCCS)
AZDF6555OtherRR MEDICARE
AZDF6555OtherRR MEDICARE