Healthcare Provider Details

I. General information

NPI: 1427375724
Provider Name (Legal Business Name): PERFORMANCE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2010
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 VALENCIA DR
IDAHO FALLS ID
83404-7575
US

IV. Provider business mailing address

1940 S BONITO WAY STE 190
MERIDIAN ID
83642-5618
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-3332
  • Fax:
Mailing address:
  • Phone: 208-287-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-954
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberDME14657
License Number StateID

VIII. Authorized Official

Name: STEPHANIE LIDDLE
Title or Position: OWNER/MANAGER
Credential: MPT
Phone: 208-521-5691