Healthcare Provider Details

I. General information

NPI: 1316015548
Provider Name (Legal Business Name): PERFORMANCE ORTHOTICS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 OAKFIELD DR
COLUMBIA MO
65202-2280
US

IV. Provider business mailing address

2409 OAKFIELD DR
COLUMBIA MO
65202-2280
US

V. Phone/Fax

Practice location:
  • Phone: 573-268-6750
  • Fax:
Mailing address:
  • Phone: 573-268-6750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. KENNETH WAYNE NEIGHBORS
Title or Position: OWNER
Credential: C.O., B.O.C.O.
Phone: 573-268-6750