Provider Demographics
NPI:1528462165
Name:MIDWAY PAIN CENTER, LLC
Entity type:Organization
Organization Name:MIDWAY PAIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-821-5140
Mailing Address - Street 1:1400 TORRENCE AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-5522
Mailing Address - Country:US
Mailing Address - Phone:708-821-5140
Mailing Address - Fax:
Practice Address - Street 1:1400 TORRENCE AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5522
Practice Address - Country:US
Practice Address - Phone:708-821-5140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty