Healthcare Provider Details

I. General information

NPI: 1255609574
Provider Name (Legal Business Name): JERSEYVILLE PAIN MANAGEMENT CENTER, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 VAUGHN RD
WOOD RIVER IL
62095-1898
US

IV. Provider business mailing address

2980 N BEVERLY GLEN CIR SUITE 301
LOS ANGELES CA
90077-1726
US

V. Phone/Fax

Practice location:
  • Phone: 618-259-3321
  • Fax:
Mailing address:
  • Phone: 310-474-9809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DR. BUD CHOMHIRUN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 618-259-3321