Provider Demographics
NPI:1538314414
Name:PERFORMANCE CHIROPRACTIC OF SOUTHERN ILLINOIS LLC
Entity Type:Organization
Organization Name:PERFORMANCE CHIROPRACTIC OF SOUTHERN ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:AUGUST
Authorized Official - Last Name:GULLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-997-3257
Mailing Address - Street 1:3905 W ERNESTINE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5800
Mailing Address - Country:US
Mailing Address - Phone:618-997-3257
Mailing Address - Fax:
Practice Address - Street 1:3905 W ERNESTINE DR
Practice Address - Street 2:SUITE B
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5800
Practice Address - Country:US
Practice Address - Phone:618-997-3257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011259111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty