=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730461963
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERFORMANCE ENHANCEMENT CONCEPTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2011
-----------------------------------------------------
Last Update Date | 09/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 WALNUT ST
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07648-1335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-750-4700
-----------------------------------------------------
Fax | 201-750-4701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 WALNUT ST
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07648-1335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-750-4700
-----------------------------------------------------
Fax | 201-750-4701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. WILLIAM GILLIGAN
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 201-750-4700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA00376400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------