=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437767753
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED HEALTH & PAIN CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2020
-----------------------------------------------------
Last Update Date | 07/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2016 W CHICAGO AVE FL 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-5548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-620-3692
-----------------------------------------------------
Fax | 312-668-8603
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2016 W CHICAGO AVE FL 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-5548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-620-3692
-----------------------------------------------------
Fax | 312-668-8603
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. YASHAR GHORESHI
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 312-931-0389
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------