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General NPI Number Information
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NPI Number | 1447782404
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Entity Type | Organization
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Legal Business Name | OPTIMAL PERFORMANCE LLC
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Dates
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Enumeration Date | 03/29/2017
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Last Update Date | 03/29/2017
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Provider Practice Location Address
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Address Line | 11312 HIAWATHA LN
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City | INDIAN HEAD PARK
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State | IL
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Zip | 60525-4332
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Country | US
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Telephone | 630-319-8183
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Fax |
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Provider Business Mailing Address
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Address Line | 11312 HIAWATHA LN
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City | INDIAN HEAD PARK
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State | IL
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Zip | 60525-4332
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTIC PHYSICIAN
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Name | DR. ROBERT VERCHOTA
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Credential |
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Telephone | 630-319-8183
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038.011471
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License Number State | IL
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