Provider Demographics
NPI:1083731608
Name:GRUNDY COUNTY PAIN CENTER SC
Entity Type:Organization
Organization Name:GRUNDY COUNTY PAIN CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-942-6511
Mailing Address - Street 1:425 E US ROUTE 6
Mailing Address - Street 2:SUITE A
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-9042
Mailing Address - Country:US
Mailing Address - Phone:815-942-6511
Mailing Address - Fax:815-942-6582
Practice Address - Street 1:425 E US ROUTE 6
Practice Address - Street 2:SUITE A
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-9042
Practice Address - Country:US
Practice Address - Phone:815-942-6511
Practice Address - Fax:815-942-6582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042617968111N00000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4760100001Medicare NSC
IL209906Medicare PIN