Basic Information
Provider Information | |||||||||
NPI: | 1225385131 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INNOVATIVE PAIN SPECIALISTS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
Address2: | SUITE 301 | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900771726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3104749809 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2101 S ARLINGTON HEIGHTS RD | ||||||||
Address2: | SUITE 165 | ||||||||
City: | ARLINGTON HEIGHTS | ||||||||
State: | IL | ||||||||
PostalCode: | 600054185 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475936800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2012 | ||||||||
LastUpdateDate: | 08/09/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOUIS | ||||||||
AuthorizedOfficialFirstName: | DEMETRIOS | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
AuthorizedOfficialTelephone: | 8475936800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | INNOVATIVE PAIN SPECIALISTS LLC | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X |   |   | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
No ID Information.