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General NPI Number Information
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NPI Number | 1902210644
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Entity Type | Organization
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Legal Business Name | PERFORMANCE REHAB WELLNESS CENTER
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Dates
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Enumeration Date | 06/19/2014
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Last Update Date | 06/19/2014
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Provider Practice Location Address
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Address Line | 12389 SAN YSIDRO ST
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City | VICTORVILLE
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State | CA
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Zip | 92392-6623
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Country | US
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Telephone | 760-490-4524
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Fax | 760-927-3268
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Provider Business Mailing Address
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Address Line | 12389 SAN YSIDRO ST
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City | VICTORVILLE
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State | CA
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Zip | 92392-6623
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Country | US
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Telephone | 760-490-4524
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Fax | 760-927-3268
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Authorized Official
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Title or Position | PARTNER
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Name | MRS. HAZEL NIKKI MANGAOANG DAVID
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Credential |
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Telephone | 760-490-4524
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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