Healthcare Provider Details

I. General information

NPI: 1184057143
Provider Name (Legal Business Name): PEAK PHYSICAL THERAPY SPORTS AND PERFORMANCE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GREGORY DR
SOUTH BURLINGTON VT
05403-6080
US

IV. Provider business mailing address

21 GREGORY DR
SOUTH BURLINGTON VT
05403-6080
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-0949
  • Fax:
Mailing address:
  • Phone: 802-658-0949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number040.0002127
License Number StateVT

VIII. Authorized Official

Name: MS. SUSAN DODGE
Title or Position: PRESIDENT
Credential: PT
Phone: 802-658-0949