Provider Demographics
NPI:1306157300
Name:PERFORMANCE SPINE AND SPORTS PHYSICIANS, PC
Entity type:Organization
Organization Name:PERFORMANCE SPINE AND SPORTS PHYSICIANS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-935-0719
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:STE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:824 MAIN ST
Practice Address - Street 2:STE 201
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-4478
Practice Address - Country:US
Practice Address - Phone:610-935-0719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERFORMANCE SPINE AND SPORTS PHYSICIANS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-24
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site