Healthcare Provider Details

I. General information

NPI: 1801061650
Provider Name (Legal Business Name): CENTER FOR PAIN MANAGEMENT & REHAB S. C .
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE AVE SUITE 117
PEORIA IL
61614-5095
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE SUITE 117
PEORIA IL
61614-5095
US

V. Phone/Fax

Practice location:
  • Phone: 309-689-8888
  • Fax: 309-689-8410
Mailing address:
  • Phone: 309-689-8888
  • Fax: 309-689-8410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number036113585
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number036113585
License Number StateIL

VIII. Authorized Official

Name: DR. YIBING LI
Title or Position: PRESIDENT
Credential: MD
Phone: 309-696-3300