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General NPI Number Information
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NPI Number | 1255648473
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Entity Type | Organization
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Legal Business Name | PERFORMANCE CHIROPRACTIC & WELLNESS
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Dates
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Enumeration Date | 09/09/2010
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Last Update Date | 09/09/2010
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Provider Practice Location Address
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Address Line | 1041 PARK DR
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City | GREENSBORO
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State | GA
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Zip | 30642-3465
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Country | US
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Telephone | 706-999-9868
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Fax | 706-622-5388
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Provider Business Mailing Address
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Address Line | 1041 PARK DR
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City | GREENSBORO
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State | GA
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Zip | 30642-3465
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Country | US
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Telephone | 706-999-9868
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Fax | 706-622-5388
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEROME JOSEPH RERUCHA
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Credential | DC
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Telephone | 706-999-9868
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | CHIR007549
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License Number State | GA
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