1184381196 NPI number — CARDINAL INTERVENTIONAL PAIN CLINIC PLLC

Table of content: (NPI 1184381196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184381196 NPI number — CARDINAL INTERVENTIONAL PAIN CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARDINAL INTERVENTIONAL PAIN CLINIC 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:
1184381196
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6501 LAKEVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2717 SUMMERHILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-3957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-642-2943
Provider Business Practice Location Address Fax Number:
877-540-9887
Provider Enumeration Date:
11/24/2021

Additional Information

Authorized Official

Authorized Official Last Name:
SIMON
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
ACOUNT MANAGER
Authorized Official Telephone Number:
214-642-2943

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1235137019 . This is a "TYPE I NPI" identifier . This identifiers is of the category "OTHER".




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