=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295858595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH, PAIN & SPINE CENTER S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1824 W 47TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60609-3842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-890-1726
-----------------------------------------------------
Fax | 773-890-1203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8333 W MAYNARD RD
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60714-1057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VICTOR P GUTIERREZ
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 773-890-1726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038-010564
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------