Provider Demographics
NPI:1366822538
Name:ADVANCE MYOTHERAPY & PAIN CTR.
Entity Type:Organization
Organization Name:ADVANCE MYOTHERAPY & PAIN CTR.
Other - Org Name:NIMFA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIMFA
Authorized Official - Middle Name:BADILLO
Authorized Official - Last Name:ANDRADE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, MMT
Authorized Official - Phone:847-257-7286
Mailing Address - Street 1:1600 W DEMPSTER ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1109
Mailing Address - Country:US
Mailing Address - Phone:847-257-7286
Mailing Address - Fax:
Practice Address - Street 1:1600 W DEMPSTER ST
Practice Address - Street 2:SUITE 106
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1109
Practice Address - Country:US
Practice Address - Phone:847-257-7286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227003426302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1346667839OtherMANUAL THERAPY