Basic Information
| Provider Information | |||||||||
| NPI: | 1801273800 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANCHESTER INTERVENTIONAL PAIN CENTER LLC | ||||||||
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| Address1: | PO BOX 674032 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752674032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724791115 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1305 AIRPORT FWY | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | BEDFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760216605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175712607 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2015 | ||||||||
| LastUpdateDate: | 04/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | WALLS | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9727887500 | ||||||||
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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.