Healthcare Provider Details

I. General information

NPI: 1740674050
Provider Name (Legal Business Name): GUARDIAN HEADACHE AND PAIN MANAGEMENT INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3747 FRANKLIN AVE SUITE 200
LONG BEACH CA
90808-1334
US

IV. Provider business mailing address

PO BOX 570
LAKE FOREST IL
60045-0570
US

V. Phone/Fax

Practice location:
  • Phone: 224-231-4363
  • Fax:
Mailing address:
  • Phone: 224-231-4363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN TAIMOORAZY
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 224-231-4363