Provider Demographics
NPI:1366697658
Name:CHRONIC PAIN RESOURCES, LLC
Entity type:Organization
Organization Name:CHRONIC PAIN RESOURCES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GULAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MUKHDOMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-751-5500
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-0037
Mailing Address - Country:US
Mailing Address - Phone:937-751-5500
Mailing Address - Fax:
Practice Address - Street 1:4215 GANTZ RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123
Practice Address - Country:US
Practice Address - Phone:937-751-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty