Provider Demographics
NPI:1427072982
Name:ADVANCED PERFORMANCE PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:ADVANCED PERFORMANCE PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MS
Authorized Official - Phone:208-232-6490
Mailing Address - Street 1:333 N 18TH AVE
Mailing Address - Street 2:STE D-2
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3358
Mailing Address - Country:US
Mailing Address - Phone:208-232-6490
Mailing Address - Fax:208-234-4805
Practice Address - Street 1:333 N 18TH AVE
Practice Address - Street 2:STE D-2
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3358
Practice Address - Country:US
Practice Address - Phone:208-232-6490
Practice Address - Fax:208-234-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1003225100000X
IDPT1535225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805858600Medicaid
1653100Medicare ID - Type Unspecified