Provider Demographics
NPI:1174660161
Name:PERFORMANCE HEALTH MEDICAL GROUP
Entity Type:Organization
Organization Name:PERFORMANCE HEALTH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARRICO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-540-9699
Mailing Address - Street 1:21707 HAWTHORNE BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503
Mailing Address - Country:US
Mailing Address - Phone:310-540-9699
Mailing Address - Fax:310-540-9486
Practice Address - Street 1:13252 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-2204
Practice Address - Country:US
Practice Address - Phone:714-740-1778
Practice Address - Fax:714-740-1913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18860AOtherMEDICARE