Healthcare Provider Details

I. General information

NPI: 1417361197
Provider Name (Legal Business Name): PERFORMANCE ENHANCEMENT PROFESSIONALS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 S STATE ST SUITE 7
DOVER DE
19901-6932
US

IV. Provider business mailing address

71 MCBRY DR
DOVER DE
19901-4407
US

V. Phone/Fax

Practice location:
  • Phone: 302-423-0236
  • Fax:
Mailing address:
  • Phone: 302-423-0236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberJ1-0000429
License Number StateDE

VIII. Authorized Official

Name: MR. GLENN P BROWN
Title or Position: PRESIDENT
Credential: PT
Phone: 302-423-0236