Provider Demographics
NPI:1508378738
Name:PERFORMANCE MEDICINE LLC
Entity Type:Organization
Organization Name:PERFORMANCE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-709-9822
Mailing Address - Street 1:3050 POST OAK BLVD STE 510
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-6512
Mailing Address - Country:US
Mailing Address - Phone:866-943-2384
Mailing Address - Fax:713-885-9572
Practice Address - Street 1:110 W VINE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40507-1658
Practice Address - Country:US
Practice Address - Phone:859-208-6781
Practice Address - Fax:859-208-6803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-27
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty