Provider Demographics
NPI:1619113677
Name:PERFORMANCE MEDICAL & REHAB CENTER, INC.
Entity Type:Organization
Organization Name:PERFORMANCE MEDICAL & REHAB CENTER, INC.
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:SUITE 201
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-7010
Mailing Address - Country:US
Mailing Address - Phone:310-540-9699
Mailing Address - Fax:310-540-9486
Practice Address - Street 1:6800 INDIANA AVE.
Practice Address - Street 2:#120
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:714-740-1778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty