Healthcare Provider Details

I. General information

NPI: 1487745477
Provider Name (Legal Business Name): PERFORMANCE CHIROPRACTIC AND SPORTS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 NE 3RD ST SUITE 220
GRAND RAPIDS MN
55744
US

IV. Provider business mailing address

104 NE 3RD ST SUITE 220
GRAND RAPIDS MN
55744
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-0604
  • Fax: 218-326-1509
Mailing address:
  • Phone: 218-326-0604
  • Fax: 218-326-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4472
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateMN

VIII. Authorized Official

Name: MR. ADAM ZACHMAN
Title or Position: OWNER
Credential: DC
Phone: 218-326-0604