1750355996 NPI number — PERFORMANCE THERAPEUTICS PLLC

Table of content: (NPI 1750355996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750355996 NPI number — PERFORMANCE THERAPEUTICS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFORMANCE THERAPEUTICS PLLC
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:
PERFORMANCE THERAPEUTICS PLLC
Provider Other Organization Name Type Code:
3
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:
1750355996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2502 W FREDDY GONZALES DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
EDINBURG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78539-7387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-381-1600
Provider Business Mailing Address Fax Number:
956-381-1616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 LINDBERG AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78501-2924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-687-4560
Provider Business Practice Location Address Fax Number:
956-618-1342
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PALOMIN
Authorized Official First Name:
OMAR
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
956-381-1600

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1139541 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 610717400 . This is a "WORKERS COMPENSATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0030KM . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 161271501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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