MEDICARE: PERFORMANCE PHYSICAL THERAPY, 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	225100000X	Physical Therapist	PT001503	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1700835410	OTHER		NPI INDIVIDUAL NUMBER

General Provider Information

NPI Number	:	1508166604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE PHYSICAL THERAPY, PLLC

Provider Business Mailing Address
First Line	:	2061 LEXINGTON RD
Second Line	:
City	:	NICHOLASVILLE
State	:	KY
Zip	:	40356-9704
Country	:	US
Telephone Number	:	859-887-0599
Fax Number	:	859-887-0979

Provider Business Practice Location Address
First Line	:	2061 LEXINGTON RD
Second Line	:
City	:	NICHOLASVILLE
State	:	KY
Zip	:	40356-9704
Country	:	US
Telephone Number	:	859-887-0599
Fax Number	:	859-887-0979

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MR. SCOTT SAMUEL CROOK
Credential	:	P.T.
Telephone Number	:	859-887-0599

Provider Enumeration Date	:	10/25/2010
Last Update Date	:	01/26/2011

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