Provider Demographics
NPI:1619277654
Name:PERFORMANCE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:PERFORMANCE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-628-2155
Mailing Address - Street 1:237 N BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-4543
Mailing Address - Country:US
Mailing Address - Phone:435-628-2155
Mailing Address - Fax:
Practice Address - Street 1:237 N BLUFF ST
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-4543
Practice Address - Country:US
Practice Address - Phone:435-628-2155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT77272101202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty