Healthcare Provider Details

I. General information

NPI: 1477982833
Provider Name (Legal Business Name): PERFORMANCE SPINE & SPORTS SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 WESTOVER TER SUITE B
GREENSBORO NC
27408-7130
US

IV. Provider business mailing address

1507 WESTOVER TER SUITE B
GREENSBORO NC
27408-7130
US

V. Phone/Fax

Practice location:
  • Phone: 336-501-3796
  • Fax: 336-333-5477
Mailing address:
  • Phone: 336-501-3796
  • Fax: 336-333-5477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2007-00213
License Number StateNC

VIII. Authorized Official

Name: MRS. GAIL REVIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 336-501-3796