Basic Information
| Provider Information | |||||||||
| NPI: | 1316387772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHICAGO LAND PAIN CENTERS SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 SOUTH IL ROUTE 31 | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153441192 | ||||||||
| FaxNumber: | 8153448070 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 S IL ROUTE 31 | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600505415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153441192 | ||||||||
| FaxNumber: | 8153448070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2013 | ||||||||
| LastUpdateDate: | 02/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | HUI | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7737673822 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.