MEDICARE: PERFORMANCE OPTIMAL HEALTH BONITA SPRINGS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1033836713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE OPTIMAL HEALTH BONITA SPRINGS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 402
Second Line	:
City	:	COS COB
State	:	CT
Zip	:	06807-0402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9122 BONITA BEACH RD SE
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34135-4207
Country	:	US
Telephone Number	:	239-342-1340
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER & CEO
Name	:	TODD WILKOWSKI
Credential	:	DPT
Telephone Number	:	877-379-4911

Provider Enumeration Date	:	10/24/2022
Last Update Date	:	10/24/2022

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