=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043520752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERFORMANCE THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2010
-----------------------------------------------------
Last Update Date | 04/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1457 N ROCHESTER RD
-----------------------------------------------------
City | ROCHESTER HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48307-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-759-4446
-----------------------------------------------------
Fax | 248-759-4448
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1457 N ROCHESTER RD
-----------------------------------------------------
City | ROCHESTER HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48307-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-759-4446
-----------------------------------------------------
Fax | 248-759-4448
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER / PARTNER
-----------------------------------------------------
Name | MR. ERIC JOSEPH VAN HULLE
-----------------------------------------------------
Credential | M.P.T., O.M.P.T.
-----------------------------------------------------
Telephone | 586-344-7449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 5501010847
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------