Basic Information
| Provider Information | |||||||||
| NPI: | 1669631347 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKEFRONT PAIN PARTNERS , LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 269092 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731269092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724791115 | ||||||||
| FaxNumber: | 9723468013 | ||||||||
| Practice Location | |||||||||
| Address1: | 6435 S FM 549 STE 102 | ||||||||
| Address2: | |||||||||
| City: | HEATH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750326221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722344740 | ||||||||
| FaxNumber: | 9722317095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2008 | ||||||||
| LastUpdateDate: | 06/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | POPE | ||||||||
| AuthorizedOfficialFirstName: | CARLETTA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9724791115 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.