1326384595 NPI number — STONEBROOK INTERVENTIONAL PAIN CENTER LLC

Table of content: (NPI 1326384595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326384595 NPI number — STONEBROOK INTERVENTIONAL PAIN CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONEBROOK INTERVENTIONAL PAIN CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326384595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 674315
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75267-4315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-479-1115
Provider Business Mailing Address Fax Number:
972-346-8015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 SUMMIT AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
FT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76102-4413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-334-0990
Provider Business Practice Location Address Fax Number:
817-571-0897
Provider Enumeration Date:
12/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GROSBECK
Authorized Official First Name:
TED
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
469-362-6909

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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