Provider Demographics
NPI:1396903795
Name:PERFORMANCE CHIROPRACTIC
Entity type:Organization
Organization Name:PERFORMANCE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WIEBE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:802-878-4946
Mailing Address - Street 1:131 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3626
Mailing Address - Country:US
Mailing Address - Phone:802-878-4946
Mailing Address - Fax:802-878-9625
Practice Address - Street 1:131 PEARL ST
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-3626
Practice Address - Country:US
Practice Address - Phone:802-878-4946
Practice Address - Fax:802-878-9625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006-0001098111NS0005X
VT006-0001086111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTWI VN2700Medicaid
VTU86699Medicare UPIN
VTU86985Medicare UPIN
VTWI VN2700Medicaid
VTWI VN 2683Medicare PIN