Provider Demographics
NPI:1114385986
Name:LOCKPORT PAIN MANAGEMENT, LTD
Entity type:Organization
Organization Name:LOCKPORT PAIN MANAGEMENT, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:RADCLIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-838-9441
Mailing Address - Street 1:400 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-3241
Mailing Address - Country:US
Mailing Address - Phone:815-838-9441
Mailing Address - Fax:
Practice Address - Street 1:400 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-3241
Practice Address - Country:US
Practice Address - Phone:815-838-9441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty