MEDICARE: PERMIAN BACK TREATMENT CENTER, PA

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	111N00000X	Chiropractor	5710	TX
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	K4046	TX
3	208100000X	Physical Medicine & Rehabilitation Physician		TX

General Provider Information

NPI Number	:	1770911299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERMIAN BACK TREATMENT CENTER, PA

Provider Business Mailing Address
First Line	:	1030 N GRANDVIEW AVE
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79761-3149
Country	:	US
Telephone Number	:	432-332-3388
Fax Number	:	432-332-3390

Provider Business Practice Location Address
First Line	:	1030 N GRANDVIEW AVE
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79761-3149
Country	:	US
Telephone Number	:	432-332-3388
Fax Number	:	432-332-3390

Authorized Official
Title or Position	:	ORGANIZER
Name	:	DR. CARL BROWN
Credential	:	D.O.
Telephone Number	:	432-332-2858

Provider Enumeration Date	:	10/18/2013
Last Update Date	:	04/16/2014

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