MEDICARE: PERFORMANCE CHIROPRACTIC PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	798	ND

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	713023	OTHER	ND	PTAN

General Provider Information

NPI Number	:	1720237258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE CHIROPRACTIC PLLC

Provider Business Mailing Address
First Line	:	4350 S WASHINGTON ST
Second Line	:	SUITE 100
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-7184
Country	:	US
Telephone Number	:	701-732-2888
Fax Number	:	701-732-2711

Provider Business Practice Location Address
First Line	:	4350 S WASHINGTON ST
Second Line	:	SUITE 100
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-7184
Country	:	US
Telephone Number	:	701-732-2888
Fax Number	:	701-732-2711

Authorized Official
Title or Position	:	CHIROPRACTOR/OWNER
Name	:	DR. STACY LANE HALLGREN
Credential	:	DC, CCEP, CST
Telephone Number	:	701-732-2888

Provider Enumeration Date	:	09/09/2008
Last Update Date	:	01/09/2015

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