Provider Demographics
NPI:1255648473
Name:PERFORMANCE CHIROPRACTIC & WELLNESS
Entity type:Organization
Organization Name:PERFORMANCE CHIROPRACTIC & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:RERUCHA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-999-9868
Mailing Address - Street 1:1041 PARK DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-3465
Mailing Address - Country:US
Mailing Address - Phone:706-999-9868
Mailing Address - Fax:706-622-5388
Practice Address - Street 1:1041 PARK DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-3465
Practice Address - Country:US
Practice Address - Phone:706-999-9868
Practice Address - Fax:706-622-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007549261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center