Provider Demographics
NPI:1255609574
Name:JERSEYVILLE PAIN MANAGEMENT CENTER, S.C.
Entity type:Organization
Organization Name:JERSEYVILLE PAIN MANAGEMENT CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BUD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOMHIRUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-259-3321
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:1702 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1898
Practice Address - Country:US
Practice Address - Phone:618-259-3321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JERSEYVILLE PAIN MANAGEMENT CENTER, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-01
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site