MEDICARE: PRO PERFORMANCE PHYSICAL THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1215598529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO PERFORMANCE PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	2544 E SUNRISE BLVD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3228
Country	:	US
Telephone Number	:	954-253-0863
Fax Number	:	954-416-3625

Provider Business Practice Location Address
First Line	:	2544 E SUNRISE BLVD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3228
Country	:	US
Telephone Number	:	954-253-0863
Fax Number	:	954-416-3625

Authorized Official
Title or Position	:	OWNER
Name	:	MICAH KUST
Credential	:
Telephone Number	:	262-565-7950

Provider Enumeration Date	:	06/26/2019
Last Update Date	:	06/26/2019

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