=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144429283
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHIROPRACTIC PERFORMANCE CENTER, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2007
-----------------------------------------------------
Last Update Date | 01/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2380 TROOP DRIVE SUTIE 201
-----------------------------------------------------
City | SARTELL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56377-4637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-255-0961
-----------------------------------------------------
Fax | 320-258-4001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2380 TROOP DRIVE SUITE 201
-----------------------------------------------------
City | SARTELL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56377-4637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-255-0961
-----------------------------------------------------
Fax | 320-258-4001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SARA JEAN CUPERUS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 320-255-0961
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 786
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------