Healthcare Provider Details

I. General information

NPI: 1598061103
Provider Name (Legal Business Name): GUARDIAN HEADACHE & PAIN MANAGEMENT INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 EASTLAND DR SUITE 7
BLOOMINGTON IL
61704-7918
US

IV. Provider business mailing address

PO BOX 5488
PEORIA IL
61601-5488
US

V. Phone/Fax

Practice location:
  • Phone: 800-444-6110
  • Fax: 847-615-2858
Mailing address:
  • Phone: 800-444-6110
  • Fax: 847-615-2858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BENJAMIN TAIMOORAZY
Title or Position: OWNER
Credential: MD
Phone: 309-287-7601