Provider Demographics
NPI:1881888485
Name:ADVANCED SPINE & JOINT REHABILITATION SERVICE CORP
Entity type:Organization
Organization Name:ADVANCED SPINE & JOINT REHABILITATION SERVICE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:WASSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-848-1708
Mailing Address - Street 1:1555 NAPERVILLE WHEATON RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-1557
Mailing Address - Country:US
Mailing Address - Phone:630-848-1708
Mailing Address - Fax:630-566-1585
Practice Address - Street 1:1555 NAPERVILLE WHEATON RD
Practice Address - Street 2:SUITE 206
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1557
Practice Address - Country:US
Practice Address - Phone:630-848-1708
Practice Address - Fax:630-566-1585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008808111N00000X
IL1640091972133VN1006X
IL036043862207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILY50711Medicare UPIN
IL213061Medicare PIN