Healthcare Provider Details

I. General information

NPI: 1619113677
Provider Name (Legal Business Name): PERFORMANCE MEDICAL & REHAB CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 12/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 INDIANA AVE. #120
RIVERSIDE CA
92506
US

IV. Provider business mailing address

21707 HAWTHORNE BLVD. SUITE 201
TORRANCE CA
90503-7010
US

V. Phone/Fax

Practice location:
  • Phone: 714-740-1778
  • Fax:
Mailing address:
  • Phone: 310-540-9699
  • Fax: 310-540-9486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: BRIAN D. CARRICO
Title or Position: OWNER
Credential: D.C.
Phone: 310-540-9699