Provider Demographics
NPI:1720237258
Name:PERFORMANCE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:PERFORMANCE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:HALLGREN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCEP, CST
Authorized Official - Phone:701-732-2888
Mailing Address - Street 1:4350 S WASHINGTON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-7184
Mailing Address - Country:US
Mailing Address - Phone:701-732-2888
Mailing Address - Fax:701-732-2711
Practice Address - Street 1:4350 S WASHINGTON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-7184
Practice Address - Country:US
Practice Address - Phone:701-732-2888
Practice Address - Fax:701-732-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND798111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14609Medicaid
MN1407036627Medicaid
ND713023OtherPTAN
ND14609Medicaid