Provider Demographics
NPI:1043783699
Name:ADVANCED NEURO PAIN CLINIC INC
Entity Type:Organization
Organization Name:ADVANCED NEURO PAIN CLINIC INC
Other - Org Name:ADVANCED NEURO PAIN CLINIC INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GIOVANNI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-276-3333
Mailing Address - Street 1:9314 S OCTAVIA AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-2110
Mailing Address - Country:US
Mailing Address - Phone:773-719-7744
Mailing Address - Fax:
Practice Address - Street 1:4009 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-2103
Practice Address - Country:US
Practice Address - Phone:773-276-3333
Practice Address - Fax:773-276-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-07
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty