Provider Demographics
NPI:1538925938
Name:PERFORMANCE SPORTSPHYSIO, LLC
Entity type:Organization
Organization Name:PERFORMANCE SPORTSPHYSIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOMOKI
Authorized Official - Middle Name:KEN
Authorized Official - Last Name:USUI
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:720-548-0068
Mailing Address - Street 1:16321 GRAHAM PEAK WAY
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-8326
Mailing Address - Country:US
Mailing Address - Phone:720-548-0068
Mailing Address - Fax:
Practice Address - Street 1:1325 DRY CREEK DR STE 307
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-7751
Practice Address - Country:US
Practice Address - Phone:720-548-0068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-23
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty