Provider Demographics
NPI:1336864099
Name:740 PERFORMANCE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:740 PERFORMANCE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:740-683-5081
Mailing Address - Street 1:2390 RIX MILLS RD
Mailing Address - Street 2:
Mailing Address - City:NEW CONCORD
Mailing Address - State:OH
Mailing Address - Zip Code:43762-9786
Mailing Address - Country:US
Mailing Address - Phone:740-683-5081
Mailing Address - Fax:
Practice Address - Street 1:2390 RIX MILLS RD
Practice Address - Street 2:
Practice Address - City:NEW CONCORD
Practice Address - State:OH
Practice Address - Zip Code:43762-9786
Practice Address - Country:US
Practice Address - Phone:740-683-5081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy