Provider Demographics
NPI:1629197066
Name:GREENVILLE REHAB & PAIN CLINIC SC
Entity Type:Organization
Organization Name:GREENVILLE REHAB & PAIN CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:CHENAULT
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:618-664-4600
Mailing Address - Street 1:1105 E HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-2221
Mailing Address - Country:US
Mailing Address - Phone:618-664-4600
Mailing Address - Fax:618-664-2136
Practice Address - Street 1:1105 E HARRIS AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-2221
Practice Address - Country:US
Practice Address - Phone:618-664-4600
Practice Address - Fax:618-664-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.618745111N00000X
IL042618745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0332010OtherBCBS
IL=========OtherTAX IDENTIFICATION
IL213144Medicare PIN