MEDICARE: PRO CHIROPRACTIC AND PERFORMANCE, LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0400X	Rehabilitation Clinic/Center	3877	SC

General Provider Information

NPI Number	:	1346635752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO CHIROPRACTIC AND PERFORMANCE, LLC.

Provider Business Mailing Address
First Line	:	150 PELHAM DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29209-1320
Country	:	US
Telephone Number	:	803-227-3377
Fax Number	:	803-227-4884

Provider Business Practice Location Address
First Line	:	1014 LEESBURG RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29209-2131
Country	:	US
Telephone Number	:	803-309-3777
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PATRICK RYAN OTOOLE
Credential	:	D.C.
Telephone Number	:	803-309-3777

Provider Enumeration Date	:	04/02/2015
Last Update Date	:	04/20/2017

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