Provider Demographics
NPI:1649741166
Name:PERFORMANCE SPORTS CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:PERFORMANCE SPORTS CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-367-6110
Mailing Address - Street 1:9471 STONERIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8475
Mailing Address - Country:US
Mailing Address - Phone:218-277-8301
Mailing Address - Fax:
Practice Address - Street 1:7876 SUNWOOD DR NW STE 200
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303-5178
Practice Address - Country:US
Practice Address - Phone:612-367-6110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-10
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty