Provider Demographics
NPI:1194766808
Name:PERFORMAX PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:PERFORMAX PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANNNINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-379-7900
Mailing Address - Street 1:29100 GATEWAY BLVD.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134
Mailing Address - Country:US
Mailing Address - Phone:734-379-7900
Mailing Address - Fax:734-379-9150
Practice Address - Street 1:29100 GATEWAY BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-2764
Practice Address - Country:US
Practice Address - Phone:734-379-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236836Medicare Oscar/Certification