Provider Demographics
NPI:1861070260
Name:PERFORMANCE INTENSIVE OUTPATIENT, LLC
Entity type:Organization
Organization Name:PERFORMANCE INTENSIVE OUTPATIENT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:TERRUSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-251-0123
Mailing Address - Street 1:9525 E DOUBLETREE RANCH RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5538
Mailing Address - Country:US
Mailing Address - Phone:480-588-3745
Mailing Address - Fax:480-809-6559
Practice Address - Street 1:9525 E DOUBLETREE RANCH RD STE 105
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5538
Practice Address - Country:US
Practice Address - Phone:480-588-3745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health