Provider Demographics
NPI:1215263546
Name:PERFORMANCE PHYSICAL THERAPY AND SPORTS TRAINING, LLC
Entity type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY AND SPORTS TRAINING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:804-874-2454
Mailing Address - Street 1:9130 DICKEY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2502
Mailing Address - Country:US
Mailing Address - Phone:804-874-2454
Mailing Address - Fax:804-550-0971
Practice Address - Street 1:9130 DICKEY DR
Practice Address - Street 2:SUITE A
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2502
Practice Address - Country:US
Practice Address - Phone:804-874-2454
Practice Address - Fax:804-550-0971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202826261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy