Basic Information
| Provider Information | |||||||||
| NPI: | 1184961583 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENDERSON INTERVENTIONAL PAIN CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 674001 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752674001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724791115 | ||||||||
| FaxNumber: | 9723468015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 SUMMIT AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761024413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173340990 | ||||||||
| FaxNumber: | 8175710897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2013 | ||||||||
| LastUpdateDate: | 01/07/2013 | ||||||||
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| AuthorizedOfficialLastName: | WALLS | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9722344740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.