MEDICARE: ULTIMATE PERFORMANCE LAB 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

General Provider Information

NPI Number	:	1912856725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTIMATE PERFORMANCE LAB LLC

Provider Business Mailing Address
First Line	:	13 CEDARCONE CT
Second Line	:
City	:	NOTTINGHAM
State	:	MD
Zip	:	21236-1675
Country	:	US
Telephone Number	:	301-706-0612
Fax Number	:

Provider Business Practice Location Address
First Line	:	13 CEDARCONE CT
Second Line	:
City	:	NOTTINGHAM
State	:	MD
Zip	:	21236-1675
Country	:	US
Telephone Number	:	301-706-0612
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ PHYSICAL THERAPIST
Name	:	DR. GRANT R SULLIVAN
Credential	:	PT, DPT
Telephone Number	:	301-706-0612

Provider Enumeration Date	:	01/26/2026
Last Update Date	:	02/22/2026

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