Provider Demographics
NPI:1891341467
Name:LINCOLN PERFORMANCE AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:LINCOLN PERFORMANCE AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:IDEUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:402-239-2298
Mailing Address - Street 1:1220 ARIES DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68512-9632
Mailing Address - Country:US
Mailing Address - Phone:402-480-7070
Mailing Address - Fax:
Practice Address - Street 1:1220 ARIES DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68512-9632
Practice Address - Country:US
Practice Address - Phone:402-480-7070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-10
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty