Healthcare Provider Details

I. General information

NPI: 1164922365
Provider Name (Legal Business Name): SHRIVE HEADACHE AND PAIN CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12606 GREENVILLE AVE
DALLAS TX
75243-1921
US

IV. Provider business mailing address

PO BOX 797992
DALLAS TX
75379-7992
US

V. Phone/Fax

Practice location:
  • Phone: 210-737-4406
  • Fax: 888-770-6360
Mailing address:
  • Phone: 210-737-4406
  • Fax: 888-770-6360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberK3753
License Number StateTX

VIII. Authorized Official

Name: LANCE M HOOVER
Title or Position: ADMIN
Credential:
Phone: 210-737-4406