Healthcare Provider Details

I. General information

NPI: 1356615074
Provider Name (Legal Business Name): PHOENIX PAIN CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 N BUCKNER BLVD STE 100
DALLAS TX
75218-3498
US

IV. Provider business mailing address

1110 N BUCKNER BLVD STE 100
DALLAS TX
75218-3498
US

V. Phone/Fax

Practice location:
  • Phone: 214-324-9400
  • Fax: 214-324-9402
Mailing address:
  • Phone: 214-324-9400
  • Fax: 214-324-9402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SALVATORE R CAMPO
Title or Position: PHYSICIAN/MEMBER
Credential: DO
Phone: 214-324-9400