MEDICARE: GUARDIAN HEADACHE AND PAIN MANAGEMENT INSTITUTE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	208VP0014X	Interventional Pain Medicine Physician
2	367500000X	Certified Registered Nurse Anesthetist
3	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1740674050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUARDIAN HEADACHE AND PAIN MANAGEMENT INSTITUTE LLC

Provider Business Mailing Address
First Line	:	PO BOX 570
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-0570
Country	:	US
Telephone Number	:	224-231-4363
Fax Number	:

Provider Business Practice Location Address
First Line	:	3747 FRANKLIN AVE
Second Line	:	SUITE 200
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1334
Country	:	US
Telephone Number	:	224-231-4363
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	BENJAMIN TAIMOORAZY
Credential	:	M.D.
Telephone Number	:	224-231-4363

Provider Enumeration Date	:	03/25/2015
Last Update Date	:	03/25/2015

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