Provider Demographics
NPI:1063249282
Name:VANGUARD PERFORMANCE, LLC
Entity type:Organization
Organization Name:VANGUARD PERFORMANCE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAHLAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-338-5927
Mailing Address - Street 1:2901 CLEVELAND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2788
Mailing Address - Country:US
Mailing Address - Phone:707-338-5927
Mailing Address - Fax:844-426-0134
Practice Address - Street 1:2901 CLEVELAND AVE STE 202
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2788
Practice Address - Country:US
Practice Address - Phone:707-968-1555
Practice Address - Fax:844-426-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty