MEDICARE: PRESTON INSTITUTE OF PAIN MANAGEMENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1043513914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTON INSTITUTE OF PAIN MANAGEMENT

Provider Business Mailing Address
First Line	:	12800 PRESTON RD STE 200
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-1369
Country	:	US
Telephone Number	:	972-991-9950
Fax Number	:	972-991-4026

Provider Business Practice Location Address
First Line	:	12800 PRESTON RD STE 200
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-1369
Country	:	US
Telephone Number	:	972-991-9950
Fax Number	:	972-991-4026

Authorized Official
Title or Position	:	GEN PARTNER
Name	:	DR. CHARLES EDWARD WILLIS
Credential	:	M.D.
Telephone Number	:	972-991-9950

Provider Enumeration Date	:	12/14/2010
Last Update Date	:	12/14/2010

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