1053623801 NPI number — COMMUNITY PAIN CONSULTANTS, LTD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053623801 NPI number — COMMUNITY PAIN CONSULTANTS, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY PAIN CONSULTANTS, LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053623801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 W COURT ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901-3664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-932-7246
Provider Business Mailing Address Fax Number:
815-932-7307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 W COURT ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901-3664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-932-7246
Provider Business Practice Location Address Fax Number:
815-932-7307
Provider Enumeration Date:
07/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-932-7146

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  036065101 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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