Provider Demographics
NPI:1760711287
Name:PERFORMANCE CHIROPRACTIC & WELLNESS
Entity Type:Organization
Organization Name:PERFORMANCE CHIROPRACTIC & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:RERUCHA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-485-9917
Mailing Address - Street 1:106 VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-5863
Mailing Address - Country:US
Mailing Address - Phone:706-485-9917
Mailing Address - Fax:
Practice Address - Street 1:106 VILLAGE LN
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-5863
Practice Address - Country:US
Practice Address - Phone:706-485-9917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007549261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center