Basic Information
| Provider Information | |||||||||
| NPI: | 1619166972 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERFORMANCE INJURY CARE & SPORTS MEDICINE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3150 N MONTANA AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HELENA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 596027804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064225817 | ||||||||
| FaxNumber: | 4064225928 | ||||||||
| Practice Location | |||||||||
| Address1: | 3150 N MONTANA AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HELENA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 596027804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064225817 | ||||||||
| FaxNumber: | 4064225928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2007 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | BRAGG | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4064225817 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.