1790308500 NPI number — ADVANCED PRACTICE PAIN MANAGEMENT AND ANESTHESIA CONSULTING PLLC

Table of content: (NPI 1790308500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790308500 NPI number — ADVANCED PRACTICE PAIN MANAGEMENT AND ANESTHESIA CONSULTING PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PRACTICE PAIN MANAGEMENT AND ANESTHESIA CONSULTING 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1790308500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 TURNER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75601-6750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-655-4814
Provider Business Mailing Address Fax Number:
833-654-0699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 WILSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75652-5957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-655-4814
Provider Business Practice Location Address Fax Number:
833-654-0699
Provider Enumeration Date:
05/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
DWIGHT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-720-1459

Provider Taxonomy Codes

  • 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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