Healthcare Provider Details

I. General information

NPI: 1083731608
Provider Name (Legal Business Name): GRUNDY COUNTY PAIN CENTER SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 E US ROUTE 6 SUITE A
MORRIS IL
60450-9042
US

IV. Provider business mailing address

425 E US ROUTE 6 SUITE A
MORRIS IL
60450-9042
US

V. Phone/Fax

Practice location:
  • Phone: 815-942-6511
  • Fax: 815-942-6582
Mailing address:
  • Phone: 815-942-6511
  • Fax: 815-942-6582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number042617968
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number042617968
License Number StateIL

VIII. Authorized Official

Name: DIANE CARLSON
Title or Position: MGR
Credential:
Phone: 815-942-6511