MEDICARE: PERFORMANCE PHYSICAL 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	225100000X	Physical Therapist	PT22239	FL

General Provider Information

NPI Number	:	1700835808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	9711 VALPARAISO DR
Second Line	:	SUITE 2
City	:	MUNSTER
State	:	IN
Zip	:	46321-2866
Country	:	US
Telephone Number	:	219-922-9508
Fax Number	:	219-924-4978

Provider Business Practice Location Address
First Line	:	5100 S CLYDE MORRIS BLVD
Second Line	:	SUITE 200
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-8976
Country	:	US
Telephone Number	:	386-304-8112
Fax Number	:	386-304-8014

Authorized Official
Title or Position	:	VICE PRESIDENT OF BUSINESS AFFAIRS
Name	:	MRS. VICKI VALENTINE
Credential	:
Telephone Number	:	219-922-9508

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	08/22/2020

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