MEDICARE: THE PLATFORM PERFORMANCE AND SPORTS REHAB, PLLC

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
2	2251S0007X	Sports Physical Therapist

General Provider Information

NPI Number	:	1104506203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PLATFORM PERFORMANCE AND SPORTS REHAB, PLLC

Provider Business Mailing Address
First Line	:	15102 N 90TH AVE
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85381-3520
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8996 W UNION HILLS DR STE 107
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-3010
Country	:	US
Telephone Number	:	602-717-9361
Fax Number	:

Authorized Official
Title or Position	:	PT / CO-OWNER
Name	:	HAILEY KAUS
Credential	:
Telephone Number	:	602-717-9361

Provider Enumeration Date	:	07/24/2023
Last Update Date	:	07/24/2023

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