Provider Demographics
NPI:1619166972
Name:PERFORMANCE INJURY CARE & SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:PERFORMANCE INJURY CARE & SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-422-5817
Mailing Address - Street 1:3150 N MONTANA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59602-7804
Mailing Address - Country:US
Mailing Address - Phone:406-422-5817
Mailing Address - Fax:406-422-5928
Practice Address - Street 1:3150 N MONTANA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-7804
Practice Address - Country:US
Practice Address - Phone:406-422-5817
Practice Address - Fax:406-422-5928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT011001070Medicare PIN