Healthcare Provider Details

I. General information

NPI: 1336273317
Provider Name (Legal Business Name): THE PERFORMANCE CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 N MONTE VISTA ST
ADA OK
74820-4611
US

IV. Provider business mailing address

511 N MONTE VISTA ST
ADA OK
74820-4611
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-3633
  • Fax: 580-436-2977
Mailing address:
  • Phone: 580-436-3633
  • Fax: 580-436-2977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2218
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2218
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DAN CHARBONEAU
Title or Position: PHYSCIAL THERAPIST
Credential:
Phone: 580-436-3633