Basic Information
| Provider Information | |||||||||
| NPI: | 1164922365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHRIVE HEADACHE AND PAIN CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 797992 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753797992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107374406 | ||||||||
| FaxNumber: | 8887706360 | ||||||||
| Practice Location | |||||||||
| Address1: | 12606 GREENVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752431921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107374406 | ||||||||
| FaxNumber: | 8887706360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2018 | ||||||||
| LastUpdateDate: | 02/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | HOOVER | ||||||||
| AuthorizedOfficialFirstName: | LANCE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 2107374406 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | K3753 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.