Healthcare Provider Details

I. General information

NPI: 1003196213
Provider Name (Legal Business Name): PERFORMANCE PT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 CORPORATE DR STE 6
WAYNE NJ
07470-3120
US

IV. Provider business mailing address

15 CORPORATE DR STE 6
WAYNE NJ
07470-3120
US

V. Phone/Fax

Practice location:
  • Phone: 973-368-4907
  • Fax: 973-368-4909
Mailing address:
  • Phone: 973-368-4907
  • Fax: 973-368-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: BRAD SAMPLES
Title or Position: OWNER
Credential: DPT
Phone: 973-368-4907