Healthcare Provider Details

I. General information

NPI: 1417110834
Provider Name (Legal Business Name): PERFORMANCE MEDICAL & REHAB CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21707 HAWTHORNE BLVD SUITE 101
TORRANCE CA
90503-7010
US

IV. Provider business mailing address

21707 HAWTHORNE BLVD SUITE 201
TORRANCE CA
90503-7010
US

V. Phone/Fax

Practice location:
  • Phone: 310-540-9699
  • Fax: 310-540-9486
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 Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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