1659485894 NPI number — LEGACY PAIN ASSOCIATES, P.A.

Table of content: (NPI 1659485894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659485894 NPI number — LEGACY PAIN ASSOCIATES, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGACY PAIN ASSOCIATES, P.A.
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:
1659485894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 679113
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:
75267-8205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-953-2280
Provider Business Mailing Address Fax Number:
832-953-2829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13406 MEDICAL COMPLEX DR STE 180
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOMBALL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77375-3339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-953-2280
Provider Business Practice Location Address Fax Number:
832-953-2829
Provider Enumeration Date:
08/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BARHORST
Authorized Official First Name:
MARK
Authorized Official Middle Name:
DONALD
Authorized Official Title or Position:
OWNER, MEDICAL DIRECTOR
Authorized Official Telephone Number:
281-955-5585

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  H6026 , 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)