Healthcare Provider Details

I. General information

NPI: 1508392515
Provider Name (Legal Business Name): PREMIER PERFORMANCE PHYSICAL THERAPY AND SPORTS MEDICINE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 TRAPELO RD UNIT 2
BELMONT MA
02478-1417
US

IV. Provider business mailing address

431 TRAPELO RD
BELMONT MA
02478-1417
US

V. Phone/Fax

Practice location:
  • Phone: 617-932-1027
  • Fax: 317-932-1476
Mailing address:
  • Phone: 617-932-1027
  • Fax: 617-932-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number20432
License Number StateMA

VIII. Authorized Official

Name: DR. JUSTIN JAY WU
Title or Position: CEO
Credential: DPT, PT
Phone: 978-500-3003