Provider Demographics
NPI:1043249113
Name:PERFORMANCE PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAZER
Authorized Official - Middle Name:A
Authorized Official - Last Name:EMATA
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:517-420-0385
Mailing Address - Street 1:6540 MILLENNIUM
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-7848
Mailing Address - Country:US
Mailing Address - Phone:517-420-0385
Mailing Address - Fax:
Practice Address - Street 1:6540 MILLENNIUM
Practice Address - Street 2:SUITE 110
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-7848
Practice Address - Country:US
Practice Address - Phone:517-420-0385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty