Provider Demographics
NPI:1386967099
Name:PERFORMANCE SPINE AND SPORTS CENTER, LLC
Entity type:Organization
Organization Name:PERFORMANCE SPINE AND SPORTS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:CREECH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:731-796-6910
Mailing Address - Street 1:535 JONES RD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-9023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:332 S 36TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-5808
Practice Address - Country:US
Practice Address - Phone:731-796-6910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011628261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center