MEDICARE: PERFORM PHYSICAL THERAPY AND WELLNESS

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

General Provider Information

NPI Number	:	1821721507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORM PHYSICAL THERAPY AND WELLNESS

Provider Business Mailing Address
First Line	:	353 ORANGE AVE
Second Line	:
City	:	CORONADO
State	:	CA
Zip	:	92118-1432
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6663 EL CAJON BLVD STE E
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-2850
Country	:	US
Telephone Number	:	858-208-0465
Fax Number	:

Authorized Official
Title or Position	:	OWNER, CEO
Name	:	MEREDITH CLAIRE HAEUPTLE
Credential	:	DPT
Telephone Number	:	609-851-7719

Provider Enumeration Date	:	07/08/2022
Last Update Date	:	07/08/2022

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Directions to “PERFORM PHYSICAL THERAPY AND WELLNESS ” Practice Location

Language	Start Address	Practice Location

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