Basic Information
| Provider Information | |||||||||
| NPI: | 1831464635 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERAPEUTIC INJECTION SERVICE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 388 | ||||||||
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| City: | NEWTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671140388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162813700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 WAKARUSA DRIVE | ||||||||
| Address2: | SUITE A2 | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660493889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858568472 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2012 | ||||||||
| LastUpdateDate: | 03/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | GLASGOW | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7858568472 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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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.