Provider Demographics
NPI:1679944334
Name:MIDWEST PAIN & SPINE CENTER, LLC
Entity type:Organization
Organization Name:MIDWEST PAIN & SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUCCIANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-692-7246
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 416
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-692-7246
Mailing Address - Fax:309-692-7226
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 416
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-7246
Practice Address - Fax:309-692-7226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty