Healthcare Provider Details

I. General information

NPI: 1508378738
Provider Name (Legal Business Name): PERFORMANCE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W VINE ST
LEXINGTON KY
40507-1658
US

IV. Provider business mailing address

3050 POST OAK BLVD STE 510
HOUSTON TX
77056-6512
US

V. Phone/Fax

Practice location:
  • Phone: 859-208-6781
  • Fax: 859-208-6803
Mailing address:
  • Phone: 866-943-2384
  • Fax: 713-885-9572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KANISHA HALL
Title or Position: OWNER
Credential: MD
Phone: 202-709-9822