Provider Demographics
NPI:1922396928
Name:SHEPARD PAIN AND PERFORMANCE CARE PC
Entity Type:Organization
Organization Name:SHEPARD PAIN AND PERFORMANCE CARE PC
Other - Org Name:SHEPARD PAIN AND PERFORMANCE CARE PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-980-5706
Mailing Address - Street 1:108 OAK CREEK PLZ APT 3-12
Mailing Address - Street 2:APT 3-12
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7545
Mailing Address - Country:US
Mailing Address - Phone:815-980-5706
Mailing Address - Fax:
Practice Address - Street 1:2 AIRLINE DR
Practice Address - Street 2:SUITE 400
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3433
Practice Address - Country:US
Practice Address - Phone:815-980-5706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011982111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty