Provider Demographics
NPI:1154729838
Name:CRYSTAL LAKE CENTER FOR CHRONIC PAIN SC
Entity type:Organization
Organization Name:CRYSTAL LAKE CENTER FOR CHRONIC PAIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:KUHLMN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-356-9371
Mailing Address - Street 1:1 SOUTH NORTHWEST HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-356-9371
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTH NORTHWEST HIGHWAY
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-356-9371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty