Healthcare Provider Details

I. General information

NPI: 1962624510
Provider Name (Legal Business Name): PERFORMANCE PLUS REHABILITATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 N WOODBINE RD.
ST. JOSEPH MO
64506
US

IV. Provider business mailing address

PO BOX 6423
ST. JOSEPH MO
64506
US

V. Phone/Fax

Practice location:
  • Phone: 816-232-5113
  • Fax: 816-232-0453
Mailing address:
  • Phone: 816-232-5113
  • Fax: 816-232-0453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCE006171
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2002011893
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCE006171
License Number StateMO

VIII. Authorized Official

Name: PAMELA THERESE SMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 816-232-5113