Provider Demographics
NPI:1336292614
Name:PERFORMANCE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:PERFORMANCE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BELLEAU
Authorized Official - Suffix:
Authorized Official - Credentials:BS, DC, CCSP, CKTP
Authorized Official - Phone:920-406-8700
Mailing Address - Street 1:825 S HURON RD STE H
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8029
Mailing Address - Country:US
Mailing Address - Phone:920-406-8700
Mailing Address - Fax:920-406-8712
Practice Address - Street 1:825 S HURON RD STE H
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8029
Practice Address - Country:US
Practice Address - Phone:920-406-8700
Practice Address - Fax:920-406-8712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2670-012111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38868000Medicaid
WI38868000Medicaid