Basic Information
Provider Information | |||||||||
NPI: | 1881965408 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARROLL INTERVENTIONALPAIN CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 674319 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752674319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9724791115 | ||||||||
FaxNumber: | 9723468015 | ||||||||
Practice Location | |||||||||
Address1: | 1305 AIRPORT FWY | ||||||||
Address2: | SUITE 103 | ||||||||
City: | BEDFORD | ||||||||
State: | TX | ||||||||
PostalCode: | 760216605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8175712607 | ||||||||
FaxNumber: | 8175710897 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/13/2012 | ||||||||
LastUpdateDate: | 06/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GROSBECK | ||||||||
AuthorizedOfficialFirstName: | TED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4693626909 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Pain | 367500000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.