=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720863947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIDAL PERFORMANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2023
-----------------------------------------------------
Last Update Date | 08/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 HAYWARD ST
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02038-2153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-213-8258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 CADORET DR
-----------------------------------------------------
City | CUMBERLAND
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02864-3402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-631-1182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | SARAH LAUDONE
-----------------------------------------------------
Credential | PT, DPT, OCS, CMTPT
-----------------------------------------------------
Telephone | 508-631-1182
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------