Healthcare Provider Details

I. General information

NPI: 1861436099
Provider Name (Legal Business Name): PAIN CARE CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N WALL STREET
KANKAKEE IL
60901
US

IV. Provider business mailing address

PO BOX 623
BOURBONNAIS IL
60914-0623
US

V. Phone/Fax

Practice location:
  • Phone: 815-936-7246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number36101753
License Number StateIL

VIII. Authorized Official

Name: JASMINE MALY
Title or Position: PRESIDENT
Credential: MD
Phone: 800-444-6110