Provider Demographics
NPI:1356887475
Name:ADVANCE PERFORMANCE PAIN AND WELLNESS CENTER
Entity type:Organization
Organization Name:ADVANCE PERFORMANCE PAIN AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:FENNEMA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-456-5315
Mailing Address - Street 1:1222 N EOLA RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-9409
Mailing Address - Country:US
Mailing Address - Phone:630-499-8804
Mailing Address - Fax:630-820-1360
Practice Address - Street 1:1222 N EOLA RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-9409
Practice Address - Country:US
Practice Address - Phone:630-499-8804
Practice Address - Fax:630-820-1360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010696111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty