MEDICARE: PERFORMANCE THERAPY, 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	5501010847	MI

General Provider Information

NPI Number	:	1043520752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE THERAPY, LLC

Provider Business Mailing Address
First Line	:	1457 N ROCHESTER RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-1122
Country	:	US
Telephone Number	:	248-759-4446
Fax Number	:	248-759-4448

Provider Business Practice Location Address
First Line	:	1457 N ROCHESTER RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-1122
Country	:	US
Telephone Number	:	248-759-4446
Fax Number	:	248-759-4448

Authorized Official
Title or Position	:	MEMBER / PARTNER
Name	:	MR. ERIC JOSEPH VAN HULLE
Credential	:	M.P.T., O.M.P.T.
Telephone Number	:	586-344-7449

Provider Enumeration Date	:	10/15/2010
Last Update Date	:	04/25/2011

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