1881965408 NPI number — CARROLL INTERVENTIONALPAIN CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881965408 NPI number — CARROLL INTERVENTIONALPAIN CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARROLL INTERVENTIONALPAIN 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:
1881965408
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 674319
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:
75267-4319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-479-1115
Provider Business Mailing Address Fax Number:
972-346-8015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 AIRPORT FWY
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76021-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-571-2607
Provider Business Practice Location Address Fax Number:
817-571-0897
Provider Enumeration Date:
01/13/2012

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: "N" .
  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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