Healthcare Provider Details

I. General information

NPI: 1235611666
Provider Name (Legal Business Name): QUANTUM INTERVENTIONAL SPORTS AND SPINE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2018
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 W AIRPORT FWY STE 1
IRVING TX
75062-6223
US

IV. Provider business mailing address

1451 W AIRPORT FWY STE 1
IRVING TX
75062-6223
US

V. Phone/Fax

Practice location:
  • Phone: 469-913-6136
  • Fax: 877-559-7679
Mailing address:
  • Phone: 469-913-6136
  • Fax: 877-559-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberQ3883
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TRUNG VAN HA
Title or Position: OWNER
Credential: MD
Phone: 694-913-6136