Healthcare Provider Details

I. General information

NPI: 1285600247
Provider Name (Legal Business Name): BACK PAIN CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 MASCOUTAH AVE
BELLEVILLE IL
62220-3468
US

IV. Provider business mailing address

2516 MASCOUTAH AVE
BELLEVILLE IL
62220-3468
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-4200
  • Fax: 618-233-3428
Mailing address:
  • Phone: 618-233-4200
  • Fax: 618-233-3428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON CHRISTOPHER WALKER
Title or Position: OWNER
Credential: D.C.
Phone: 618-233-4200