1679367155 NPI number — INTERVENTIONAL PAIN SPECIALISTS, 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 1679367155 NPI number — INTERVENTIONAL PAIN SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL PAIN SPECIALISTS, 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:
1679367155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 69
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OPELOUSAS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70571-0069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-284-3200
Provider Business Mailing Address Fax Number:
800-207-6956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 S COLLEGE RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-3038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-362-8101
Provider Business Practice Location Address Fax Number:
337-761-1616
Provider Enumeration Date:
04/08/2025

Additional Information

Authorized Official

Authorized Official Last Name:
GROS
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
337-284-3200

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1049999 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1574881 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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