Basic Information
| Provider Information | |||||||||
| NPI: | 1639451925 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MATLOCK INTERVENTIONAL PAIN CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 674259 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752674259 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 603 MATLOCK CENTRE CIR | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760152535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722344740 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2011 | ||||||||
| LastUpdateDate: | 09/13/2011 | ||||||||
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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 | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.