Provider Demographics
NPI:1134531973
Name:SOUTHSIDE PAIN RELIEF CENTER INC
Entity type:Organization
Organization Name:SOUTHSIDE PAIN RELIEF CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:XIA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:312-953-9667
Mailing Address - Street 1:5569 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2356
Mailing Address - Country:US
Mailing Address - Phone:708-717-5947
Mailing Address - Fax:708-576-8491
Practice Address - Street 1:5569 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2356
Practice Address - Country:US
Practice Address - Phone:708-717-5947
Practice Address - Fax:708-576-8491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-28
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105506174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty