=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730477928
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERFORMANCE OVER PAIN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2011
-----------------------------------------------------
Last Update Date | 10/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1090 W S BOUNDARY ST STE 200
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-5278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-872-1914
-----------------------------------------------------
Fax | 419-872-1910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1090 W S BOUNDARY ST STE 200
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-5278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-872-1914
-----------------------------------------------------
Fax | 419-872-1910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MICHAEL J OLMSTEAD
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 419-872-1914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT-4650
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------