Healthcare Provider Details

I. General information

NPI: 1487889135
Provider Name (Legal Business Name): PERFORMANCE PHYSICAL THERAPY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700B GUNSTON PLZ
LORTON VA
22079-1897
US

IV. Provider business mailing address

PO BOX 243
LORTON VA
22199-0243
US

V. Phone/Fax

Practice location:
  • Phone: 703-339-3767
  • Fax: 703-339-3793
Mailing address:
  • Phone: 703-339-3767
  • Fax: 703-339-3793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2305203265
License Number StateVA

VIII. Authorized Official

Name: JENNIFER LORRAINE WELSH
Title or Position: OWNER
Credential: MSPT
Phone: 703-339-3767