Provider Demographics
NPI:1336273317
Name:THE PERFORMANCE CENTER, PLLC
Entity type:Organization
Organization Name:THE PERFORMANCE CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSCIAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARBONEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-436-3633
Mailing Address - Street 1:511 N MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4611
Mailing Address - Country:US
Mailing Address - Phone:580-436-3633
Mailing Address - Fax:580-436-2977
Practice Address - Street 1:511 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4611
Practice Address - Country:US
Practice Address - Phone:580-436-3633
Practice Address - Fax:580-436-2977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2218225100000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK700522083Medicare ID - Type UnspecifiedPHYSICAL THERAPY