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NPI Code Detail

MEDICARE: SPRUCE ANESTHESIA MANAGEMENT, LLC

MEDICARE: SPRUCE ANESTHESIA MANAGEMENT, LLC
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
1261QP3300XPain Clinic/Center
2367500000XCertified Registered Nurse Anesthetist

General Provider Information

NPI Number : 1093164196
Entity Type Code : Organization
Provider Name (Legal Business Name) : SPRUCE ANESTHESIA MANAGEMENT, LLC
Provider Business Mailing Address
First Line : PO BOX 674424
Second Line :
City : DALLAS
State : TX
Zip : 75267-4424
Country : US
Telephone Number : 817-334-0880
Fax Number : 972-346-6869
Provider Business Practice Location Address
First Line : 2001 COOPER ST
Second Line :
City : FORT WORTH
State : TX
Zip : 76104-2529
Country : US
Telephone Number : 817-334-0880
Fax Number : 972-346-6869
Authorized Official
Title or Position : PRESIDENT
Name : TRACY WALLS
Credential :
Telephone Number : 972-234-4740
Provider Enumeration Date : 06/09/2016
Last Update Date : 06/09/2016

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