Provider Demographics
NPI:1497516876
Name:PERFORMERS EDGE WELLNESS LLC
Entity type:Organization
Organization Name:PERFORMERS EDGE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MS, DPT
Authorized Official - Phone:973-222-4755
Mailing Address - Street 1:35 OLD BEAVER RUN RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:NJ
Mailing Address - Zip Code:07848-2002
Mailing Address - Country:US
Mailing Address - Phone:973-222-4755
Mailing Address - Fax:
Practice Address - Street 1:35 OLD BEAVER RUN RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:NJ
Practice Address - Zip Code:07848-2002
Practice Address - Country:US
Practice Address - Phone:973-222-4755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy