Provider Demographics
NPI:1043682792
Name:PRO PERFORMANCE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:PRO PERFORMANCE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-675-5106
Mailing Address - Street 1:11650 LANTERN ROAD
Mailing Address - Street 2:SUITE 132
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-3059
Mailing Address - Country:US
Mailing Address - Phone:386-675-5106
Mailing Address - Fax:
Practice Address - Street 1:11650 LANTERN RD
Practice Address - Street 2:SUITE 132
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2993
Practice Address - Country:US
Practice Address - Phone:386-675-5106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-21
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty