Healthcare Provider Details

I. General information

NPI: 1720237258
Provider Name (Legal Business Name): PERFORMANCE CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 S WASHINGTON ST SUITE 100
GRAND FORKS ND
58201-7184
US

IV. Provider business mailing address

4350 S WASHINGTON ST SUITE 100
GRAND FORKS ND
58201-7184
US

V. Phone/Fax

Practice location:
  • Phone: 701-732-2888
  • Fax: 701-732-2711
Mailing address:
  • Phone: 701-732-2888
  • Fax: 701-732-2711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number798
License Number StateND

VIII. Authorized Official

Name: DR. STACY LANE HALLGREN
Title or Position: CHIROPRACTOR/OWNER
Credential: DC, CCEP, CST
Phone: 701-732-2888