Basic Information
| Provider Information | |||||||||
| NPI: | 1558505909 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAPEVINE PAIN MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5750 RUFE SNOW DR | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | NORTH RICHLAND HILLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761806163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174790800 | ||||||||
| FaxNumber: | 8174790801 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 IRA E WOODS AVE | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760513997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174889991 | ||||||||
| FaxNumber: | 8174889992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2009 | ||||||||
| LastUpdateDate: | 01/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | MAYFIELD | ||||||||
| AuthorizedOfficialFirstName: | GAIL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8174790800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.