1023511045 NPI number — PERFORMANCE HEALTH MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023511045 NPI number — PERFORMANCE HEALTH MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFORMANCE HEALTH MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023511045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3328
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-636-9702
Provider Business Mailing Address Fax Number:
877-427-2307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25431 CABOT ROAD SUITE 118
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-636-9702
Provider Business Practice Location Address Fax Number:
877-427-2307
Provider Enumeration Date:
03/15/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
NCPDP COORDINATOR
Authorized Official Telephone Number:
479-636-9702

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  G45164 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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