Healthcare Provider Details

I. General information

NPI: 1043249113
Provider Name (Legal Business Name): PERFORMANCE PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6540 MILLENNIUM SUITE 110
LANSING MI
48917-7848
US

IV. Provider business mailing address

6540 MILLENNIUM SUITE 110
LANSING MI
48917-7848
US

V. Phone/Fax

Practice location:
  • Phone: 517-420-0385
  • Fax:
Mailing address:
  • Phone: 517-420-0385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501006693
License Number StateMI

VIII. Authorized Official

Name: MR. SHAZER A EMATA
Title or Position: PT
Credential: RPT
Phone: 517-420-0385