Provider Demographics
NPI:1255372256
Name:PERFORMANCE PHYSICAL THERAPY OF PORT ORANGE
Entity type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY OF PORT ORANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:386-304-8112
Mailing Address - Street 1:5100 S CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8976
Mailing Address - Country:US
Mailing Address - Phone:386-304-8112
Mailing Address - Fax:
Practice Address - Street 1:5100 S CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8976
Practice Address - Country:US
Practice Address - Phone:386-304-8112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4417Medicare PIN
FLDA4011Medicare PIN