Provider Demographics
NPI:1255728986
Name:OPTIMUM PHYSICAL THERAPY & PERFORMANCE CENTER, LLC
Entity type:Organization
Organization Name:OPTIMUM PHYSICAL THERAPY & PERFORMANCE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:816-547-6140
Mailing Address - Street 1:3610 NW 86TH CT
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64154-1283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5501 NW 62ND TER
Practice Address - Street 2:STE 102
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64151-2411
Practice Address - Country:US
Practice Address - Phone:816-547-6140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty