MEDICARE: MIDWAY PAIN CENTER, LLC

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	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1528462165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWAY PAIN CENTER, LLC

Provider Business Mailing Address
First Line	:	1400 TORRENCE AVE
Second Line	:	SUITE 209
City	:	CALUMET CITY
State	:	IL
Zip	:	60409-5522
Country	:	US
Telephone Number	:	708-821-5140
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 TORRENCE AVE
Second Line	:	SUITE 209
City	:	CALUMET CITY
State	:	IL
Zip	:	60409-5522
Country	:	US
Telephone Number	:	708-821-5140
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	RICHARD DALE
Credential	:	DC
Telephone Number	:	708-821-5140

Provider Enumeration Date	:	10/10/2014
Last Update Date	:	10/10/2014

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