Basic Information
| Provider Information | |||||||||
| NPI: | 1356627988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BURLESON INTERVENTIONAL PAIN CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 674147 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752674147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722344740 | ||||||||
| FaxNumber: | 9722317095 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 OWEN CT | ||||||||
| Address2: | SUITE 119 | ||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760634232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722344740 | ||||||||
| FaxNumber: | 9722317095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2011 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | GROSBECK | ||||||||
| AuthorizedOfficialFirstName: | TED | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4693626909 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.