Provider Demographics
NPI:1003019779
Name:TLC PAIN MANAGEMENT & SLEEP RESTORATION SC
Entity Type:Organization
Organization Name:TLC PAIN MANAGEMENT & SLEEP RESTORATION SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-359-9432
Mailing Address - Street 1:1883 HICKS RD
Mailing Address - Street 2:STE A
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-1254
Mailing Address - Country:US
Mailing Address - Phone:847-359-9432
Mailing Address - Fax:888-687-1245
Practice Address - Street 1:1883 HICKS RD
Practice Address - Street 2:STE A
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008-1254
Practice Address - Country:US
Practice Address - Phone:847-359-9432
Practice Address - Fax:888-687-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078457208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF13947Medicare UPIN
ILK132541LMedicare ID - Type Unspecified