MEDICARE: PERFORMANCE HEALTH MEDICAL GROUP, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	111NR0400X	Rehabilitation Chiropractor
2	207R00000X	Internal Medicine Physician
3	207X00000X	Orthopaedic Surgery Physician
4	363AM0700X	Medical Physician Assistant
5	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	120115601	OTHER	CA	GROUP

General Provider Information

NPI Number	:	1093896862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE HEALTH MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	25431 CABOT RD
Second Line	:	SUITE 118
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-5518
Country	:	US
Telephone Number	:	949-362-8877
Fax Number	:	949-598-8042

Provider Business Practice Location Address
First Line	:	25431 CABOT RD
Second Line	:	SUITE 118
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-5518
Country	:	US
Telephone Number	:	949-362-8877
Fax Number	:	949-598-8042

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRIAN D CARRICO
Credential	:	D.C.
Telephone Number	:	949-362-8877

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	03/25/2009

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Directions to “PERFORMANCE HEALTH MEDICAL GROUP, INC ” Practice Location

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