=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992393417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEAK PERFORMANCE SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2021
-----------------------------------------------------
Last Update Date | 01/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 668 E 9 MILE RD
-----------------------------------------------------
City | FERNDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48220-1962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-871-4805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 344 E HARRY AVE
-----------------------------------------------------
City | HAZEL PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48030-2055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-871-4805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEMBER
-----------------------------------------------------
Name | ANTWAN FARAJ
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 586-871-4805
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------