1144429283 NPI number — CHIROPRACTIC PERFORMANCE CENTER, PA

Table of content: (NPI 1144429283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144429283 NPI number — CHIROPRACTIC PERFORMANCE CENTER, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC PERFORMANCE CENTER, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144429283
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2380 TROOP DRIVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
SARTELL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56377-4637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-255-0961
Provider Business Mailing Address Fax Number:
320-258-4001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2380 TROOP DRIVE
Provider Second Line Business Practice Location Address:
SUTIE 201
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377-4637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-255-0961
Provider Business Practice Location Address Fax Number:
320-258-4001
Provider Enumeration Date:
07/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CUPERUS
Authorized Official First Name:
SARA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
320-255-0961

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  786 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 350002734 . This is a "MEDICARE INDIVIDUAL #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 332J9KL . This is a "BCBS INDIVIDUAL #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 331J2CH . This is a "BCBS - CLINIC #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 777641100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 965001033012 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: C03940 . This is a "MEIDCARE CLINIC #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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