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General NPI Number Information
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NPI Number | 1275714909
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Entity Type | Organization
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Legal Business Name | PERFORMANCE BUILDERS, LLC
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Dates
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Enumeration Date | 11/21/2007
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Last Update Date | 11/21/2007
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Provider Practice Location Address
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Address Line | 316 STICKNEY RIDGE RD
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City | GRAND HAVEN
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State | MI
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Zip | 49417-9314
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Country | US
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Telephone | 616-847-2115
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Fax |
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Provider Business Mailing Address
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Address Line | 316 STICKNEY RIDGE RD
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City | GRAND HAVEN
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State | MI
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Zip | 49417-9314
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Country | US
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Telephone | 616-847-2115
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. ROBERT N WIERSMA
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Credential | PT
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Telephone | 616-847-2115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5501001249
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License Number State | MI
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