Basic Information
| Provider Information | |||||||||
| NPI: | 1245624113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE INTERVENTIONAL PAIN CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 674102 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752674102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724791115 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1778 N PLANO RD | ||||||||
| Address2: | SUITE 300B | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750811968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722319770 | ||||||||
| FaxNumber: | 9722319761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2015 | ||||||||
| LastUpdateDate: | 04/20/2016 | ||||||||
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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 | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.