1477919686 NPI number — ASCLEPIUS PAIN MANAGEMENT, PLLC

Table of content: (NPI 1477919686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477919686 NPI number — ASCLEPIUS PAIN MANAGEMENT, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASCLEPIUS PAIN MANAGEMENT, PLLC
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:
1477919686
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 836156
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHARDSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75083-6156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-974-8990
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7920 BELT LINE RD
Provider Second Line Business Practice Location Address:
120
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75254-8145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-221-2582
Provider Business Practice Location Address Fax Number:
214-446-2323
Provider Enumeration Date:
01/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RAKOVCHIK
Authorized Official First Name:
IGOR
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
214-221-2582

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  N4020 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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