Healthcare Provider Details

I. General information

NPI: 1689150054
Provider Name (Legal Business Name): 5 STAR PERFORMANCE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 LAKELAND DR
FLOWOOD MS
39232-9583
US

IV. Provider business mailing address

4500 LAKELAND DR
FLOWOOD MS
39232-9583
US

V. Phone/Fax

Practice location:
  • Phone: 601-354-4488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GLEN SILVERMAN
Title or Position: CEO
Credential:
Phone: 601-354-4488