Healthcare Provider Details

I. General information

NPI: 1982913448
Provider Name (Legal Business Name): PINE INTERVENTIONAL PROCEDURE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17051 DALLAS PKWY STE 100
ADDISON TX
75001-7101
US

IV. Provider business mailing address

PO BOX 268989
OKLAHOMA CITY OK
73126-8989
US

V. Phone/Fax

Practice location:
  • Phone: 469-916-0521
  • Fax: 972-243-0212
Mailing address:
  • Phone: 972-479-1115
  • Fax: 972-346-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRACY WALLS
Title or Position: MANAGER
Credential:
Phone: 972-234-4140