=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932576360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERFORMANCE AND WELLNESS CHIROPRACTIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2015
-----------------------------------------------------
Last Update Date | 12/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11211 PROSPERITY FARMS RD UNIT A10
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-3446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-402-4701
-----------------------------------------------------
Fax | 561-720-2056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11211 PROSPERITY FARMS RD STE A101
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-3479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-402-4701
-----------------------------------------------------
Fax | 561-720-2056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MATTHEW DILALLO
-----------------------------------------------------
Credential | DC, MA, CSCS
-----------------------------------------------------
Telephone | 303-718-8562
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH 11621
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------