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General NPI Number Information
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NPI Number | 1407090350
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Entity Type | Organization
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Legal Business Name | THE PAIN CLINIC INC.
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Dates
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Enumeration Date | 04/22/2009
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Last Update Date | 07/22/2015
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Provider Practice Location Address
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Address Line | 3674 RIDGE RD
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City | LANSING
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State | IL
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Zip | 60438-3144
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Country | US
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Telephone | 708-474-2700
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Fax | 708-474-3300
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Provider Business Mailing Address
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Address Line | 3674 RIDGE RD
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City | LANSING
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State | IL
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Zip | 60438-3144
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Country | US
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Telephone | 708-474-2700
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Fax | 708-474-3300
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES A. GROSS
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Credential | D.C.
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Telephone | 708-474-2700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038-006292
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 204D00000X
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Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
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License Number | 036-063384
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License Number State | IL
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