=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740686658
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERICAN PAIN INSTITUTE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2014
-----------------------------------------------------
Last Update Date | 11/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1753 W CHICAGO AVE SUITE 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-226-4556
-----------------------------------------------------
Fax | 312-226-3775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1753 W CHICAGO AVE SUITE 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-226-4556
-----------------------------------------------------
Fax | 312-226-3775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JERRY DALE LEECH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-226-4556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036086950
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------