MEDICARE: PERFORMANCE PHYSICAL THERAPY AND SPORTS TRAINING, 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	2305202826	VA

General Provider Information

NPI Number	:	1215263546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE PHYSICAL THERAPY AND SPORTS TRAINING, LLC

Provider Business Mailing Address
First Line	:	9130 DICKEY DR
Second Line	:	SUITE A
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23116-2502
Country	:	US
Telephone Number	:	804-874-2454
Fax Number	:	804-550-0971

Provider Business Practice Location Address
First Line	:	9130 DICKEY DR
Second Line	:	SUITE A
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23116-2502
Country	:	US
Telephone Number	:	804-874-2454
Fax Number	:	804-550-0971

Authorized Official
Title or Position	:	OWNER / CLINIC DIRECTOR
Name	:	JENNIFER M HYDE
Credential	:	MSPT
Telephone Number	:	804-874-2454

Provider Enumeration Date	:	10/21/2009
Last Update Date	:	10/21/2009

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