Provider Demographics
NPI:1053850990
Name:PERFORMANCE CHIROPRACTIC AND SPORTS REHABILITATION, LLC.
Entity Type:Organization
Organization Name:PERFORMANCE CHIROPRACTIC AND SPORTS REHABILITATION, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:MICNHEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-690-5100
Mailing Address - Street 1:504 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW DOUGLAS
Mailing Address - State:IL
Mailing Address - Zip Code:62074-1622
Mailing Address - Country:US
Mailing Address - Phone:618-690-5100
Mailing Address - Fax:618-690-5101
Practice Address - Street 1:122 S 2ND ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1723
Practice Address - Country:US
Practice Address - Phone:618-690-5100
Practice Address - Fax:618-690-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013077111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty