Healthcare Provider Details

I. General information

NPI: 1912195330
Provider Name (Legal Business Name): MIDCITIES PAIN CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W NORTHWEST HWY STE. 1000
GRAPEVINE TX
76051-8112
US

IV. Provider business mailing address

PO BOX 269083
OKLAHOMA CITY OK
73126-9083
US

V. Phone/Fax

Practice location:
  • Phone: 817-488-9991
  • Fax:
Mailing address:
  • Phone: 972-479-1115
  • Fax: 972-346-8013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TED GROESBECK
Title or Position: VICE PRESIDENT
Credential:
Phone: 469-682-6742