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General NPI Number Information
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NPI Number | 1679352884
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Entity Type | Organization
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Legal Business Name | THE PERFORMANCE LAB
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Dates
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Enumeration Date | 09/26/2023
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Last Update Date | 09/26/2023
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Provider Practice Location Address
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Address Line | 40 UNION CITY RD STE D
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City | PROSPECT
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State | CT
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Zip | 06712-1585
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Country | US
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Telephone | 203-232-5924
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Fax |
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Provider Business Mailing Address
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Address Line | 103 PLANK RD
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City | PROSPECT
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State | CT
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Zip | 06712-1437
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Country | US
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Telephone | 203-232-5924
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | REBECCA LAVAWAY
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Credential | MSPT
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Telephone | 475-233-3311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number |
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License Number State |
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