Provider Demographics
NPI:1962624510
Name:PERFORMANCE PLUS REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:PERFORMANCE PLUS REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:THERESE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-232-5113
Mailing Address - Street 1:PO BOX 6423
Mailing Address - Street 2:
Mailing Address - City:ST. JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506
Mailing Address - Country:US
Mailing Address - Phone:816-232-5113
Mailing Address - Fax:816-232-0453
Practice Address - Street 1:1802 N WOODBINE RD.
Practice Address - Street 2:
Practice Address - City:ST. JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506
Practice Address - Country:US
Practice Address - Phone:816-232-5113
Practice Address - Fax:816-232-0453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCE006171111N00000X, 111NR0400X
MO2002011893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO20689030OtherBCBS
MO757861505Medicaid
MO757861505Medicaid
266666Medicare UPIN