MEDICARE: PAIN AND WELLNESS GROUP 2 LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	036107014	IL

General Provider Information

NPI Number	:	1023495421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN AND WELLNESS GROUP 2 LTD

Provider Business Mailing Address
First Line	:	PO BOX 9
Second Line	:
City	:	BATAVIA
State	:	IL
Zip	:	60510-0009
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 W SAINT CHARLES RD
Second Line	:
City	:	VILLA PARK
State	:	IL
Zip	:	60181-2432
Country	:	US
Telephone Number	:	630-691-1234
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LUKE LOTRIET
Credential	:
Telephone Number	:	630-691-1234

Provider Enumeration Date	:	05/05/2015
Last Update Date	:	01/24/2017

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