Basic Information
| Provider Information | |||||||||
| NPI: | 1902135767 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMBULATORY SPINE PROCEDURE CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 269083 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731269083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4699160521 | ||||||||
| FaxNumber: | 9722340212 | ||||||||
| Practice Location | |||||||||
| Address1: | 17110 DALLAS PKWY | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752481167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4699160521 | ||||||||
| FaxNumber: | 9722340212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2009 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | GROSBECK | ||||||||
| AuthorizedOfficialFirstName: | TED | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4699160521 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.