Provider Demographics
NPI:1790197044
Name:FUNCTIONAL PERFORMANCE CHIROPRACTIC, LTD
Entity Type:Organization
Organization Name:FUNCTIONAL PERFORMANCE CHIROPRACTIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ROBINETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:513-706-0145
Mailing Address - Street 1:1153 HUMMINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3409
Mailing Address - Country:US
Mailing Address - Phone:513-706-0145
Mailing Address - Fax:
Practice Address - Street 1:1153 HUMMINGBIRD LN
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-3409
Practice Address - Country:US
Practice Address - Phone:513-706-0145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012615111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty