Basic Information
| Provider Information | |||||||||
| NPI: | 1740345818 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERFORMANCE REHABILITATION OF WESTERN NEW ENGLAND LLC | ||||||||
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| OtherOrganizationName: | PERFORMANCE REHABILITATION PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 168 DENSLOW RD | ||||||||
| Address2: | |||||||||
| City: | EAST LONGMEADOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010283188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135269969 | ||||||||
| FaxNumber: | 4135269960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 10/06/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BIRON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4135269969 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHYSICAL THERAPIST | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 332B00000X | MA | N | Suppliers | Durable Medical Equipment & Medical Supplies | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251H1200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | 225X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 03527 | 01 | MA | BMC ELM GROUP | OTHER | 64-04290 | 01 | MA | UNITED GROUP | OTHER | 972730 | 01 | MA | NETWORK HEALTH GROUP | OTHER | AA49027 | 01 | MA | HARVARD PILGRIM | OTHER | 043527 | 01 | MA | CT CARE GROUP | OTHER | 35264 | 01 | MA | DENSLOW BMC GROUP | OTHER | 35265 | 01 | MA | BIRNIE BMC GROUP | OTHER | 9715568 | 05 | MA | MEDICAID | 103355100 | 01 | MA | DOL GROUP | OTHER | 9715568 | 01 | MA | MASS HEALTH GROUP | OTHER | Y61264 | 01 | MA | BLUE CROSS PT | OTHER | 28117 | 01 | MA | HNE GROUP | OTHER | 690675 | 01 | MA | TUFTS GROUP | OTHER | OG0011 | 01 | MA | BLUE CROSS | OTHER | PT0191 | 01 | MA | MEDICARE | OTHER |