MEDICARE: PERFORMANCE HEALTH CARE 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	111NS0005X	Sports Physician Chiropractor	038011404	MO

General Provider Information

NPI Number	:	1518273911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	3641 REAVIS BARRACKS RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63125-2438
Country	:	US
Telephone Number	:	636-219-9664
Fax Number	:

Provider Business Practice Location Address
First Line	:	3641 REAVIS BARRACKS RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63125-2438
Country	:	US
Telephone Number	:	636-219-9664
Fax Number	:

Authorized Official
Title or Position	:	PROPRIETOR
Name	:	MRS. MIRANDA LEIGH DAVIS
Credential	:
Telephone Number	:	636-219-9664

Provider Enumeration Date	:	08/23/2010
Last Update Date	:	08/23/2010

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