Provider Demographics
NPI:1972809036
Name:PERFORMANCE PHYSICAL THERAPY OF WESTPORT LLC
Entity type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY OF WESTPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-422-0679
Mailing Address - Street 1:9 W BROAD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3764
Mailing Address - Country:US
Mailing Address - Phone:203-557-9165
Mailing Address - Fax:203-625-8290
Practice Address - Street 1:333 POST RD W
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4701
Practice Address - Country:US
Practice Address - Phone:203-422-0679
Practice Address - Fax:203-422-0931
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERFORMANCE HEALTH CARE MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-07
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100121973Medicare PIN