Provider Demographics
NPI:1992444319
Name:PRIME PERFORMANCE REHAB, LLC
Entity type:Organization
Organization Name:PRIME PERFORMANCE REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:
Authorized Official - Last Name:LANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:803-394-6191
Mailing Address - Street 1:5200 ASHCROFT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-4115
Mailing Address - Country:US
Mailing Address - Phone:803-394-6191
Mailing Address - Fax:
Practice Address - Street 1:885 ISLAND PARK DR
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-7956
Practice Address - Country:US
Practice Address - Phone:843-640-5244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy