Provider Demographics
NPI:1770901787
Name:GENESIS PERFORMANCE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:GENESIS PERFORMANCE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VERMEESCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:484-941-4345
Mailing Address - Street 1:102 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:ELVERSON
Mailing Address - State:PA
Mailing Address - Zip Code:19520-9241
Mailing Address - Country:US
Mailing Address - Phone:610-286-9991
Mailing Address - Fax:610-286-0265
Practice Address - Street 1:102 S PINE ST
Practice Address - Street 2:
Practice Address - City:ELVERSON
Practice Address - State:PA
Practice Address - Zip Code:19520-9241
Practice Address - Country:US
Practice Address - Phone:610-286-9991
Practice Address - Fax:610-286-0265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010795111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty