Provider Demographics
NPI:1619496957
Name:VITAL PERFORMANCE LLC
Entity Type:Organization
Organization Name:VITAL PERFORMANCE LLC
Other - Org Name:VITAL PERFORMANCE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:CHARLES JEROME
Authorized Official - Last Name:BOSSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-486-6933
Mailing Address - Street 1:7827 HIGHWAY N
Mailing Address - Street 2:#102
Mailing Address - City:DARDENNE PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7827 HIGHWAY N STE 102
Practice Address - Street 2:
Practice Address - City:DARDENNE PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63368-7199
Practice Address - Country:US
Practice Address - Phone:636-486-6933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017015434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty