Provider Demographics
NPI:1225183783
Name:ELITE PERFORMANCE AND PAIN CENTER LLC
Entity Type:Organization
Organization Name:ELITE PERFORMANCE AND PAIN CENTER LLC
Other - Org Name:ACTIVE CARE FAMILY CHIROPRACTIC LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:JIMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-873-6004
Mailing Address - Street 1:761 ST. ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407
Mailing Address - Country:US
Mailing Address - Phone:843-873-6004
Mailing Address - Fax:843-766-3694
Practice Address - Street 1:761 SAINT ANDREWS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7164
Practice Address - Country:US
Practice Address - Phone:843-873-6004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3131111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV05426Medicare UPIN