1689122103 NPI number — GRAYSON INTERVENTIONAL PAIN CENTER

Table of content: (NPI 1689122103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689122103 NPI number — GRAYSON INTERVENTIONAL PAIN CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAYSON INTERVENTIONAL PAIN CENTER
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:
1689122103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 674057
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:
75267-4057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-916-0521
Provider Business Mailing Address Fax Number:
972-234-0212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 W NORTHWEST HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAPEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76051-8112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-916-0521
Provider Business Practice Location Address Fax Number:
972-234-0212
Provider Enumeration Date:
09/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WALLS
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
972-234-4740

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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