Provider Demographics
NPI:1417358490
Name:PARK PERFORMANCE CHIROPRACTIC, PLC
Entity Type:Organization
Organization Name:PARK PERFORMANCE CHIROPRACTIC, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:763-670-2990
Mailing Address - Street 1:716 1ST ST E
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1707
Mailing Address - Country:US
Mailing Address - Phone:182-366-2174
Mailing Address - Fax:218-366-2175
Practice Address - Street 1:716 1ST ST E
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1707
Practice Address - Country:US
Practice Address - Phone:182-366-2174
Practice Address - Fax:218-366-2175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5635111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty