Provider Demographics
NPI:1699292201
Name:PERFORMANCE & RECOVERY LAB, LLC.
Entity type:Organization
Organization Name:PERFORMANCE & RECOVERY LAB, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:702-443-1133
Mailing Address - Street 1:2837 N POWER RD STE 109
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1735
Mailing Address - Country:US
Mailing Address - Phone:480-625-6693
Mailing Address - Fax:480-304-3269
Practice Address - Street 1:2837 N POWER RD STE 109
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215
Practice Address - Country:US
Practice Address - Phone:480-625-6693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10208261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1407293491OtherINDIVIDUAL NPI