1417018052 NPI number — MILLENNIUM PAIN CENTER LLC

Table of content: (NPI 1417018052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417018052 NPI number — MILLENNIUM PAIN CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLENNIUM 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:
1417018052
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13111 N CENTRAL EXPY
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75243-1138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-239-2190
Provider Business Mailing Address Fax Number:
972-239-5214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13111 N CENTRAL EXPY
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75243-1138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-239-2190
Provider Business Practice Location Address Fax Number:
972-239-5214
Provider Enumeration Date:
12/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARSH
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
310-258-2400

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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