1770875197 NPI number — PERFORMANCE BIOMEDICAL LLC

Table of content: (NPI 1770875197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770875197 NPI number — PERFORMANCE BIOMEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFORMANCE BIOMEDICAL LLC
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:
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:
1770875197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10817 COURTHOUSE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22408-2627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-750-9622
Provider Business Mailing Address Fax Number:
888-688-0403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10817 COURTHOUSE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22408-2627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-750-9622
Provider Business Practice Location Address Fax Number:
888-688-0403
Provider Enumeration Date:
05/03/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FAY
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
267-750-9622

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BN1400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1027835960001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".