Healthcare Provider Details

I. General information

NPI: 1780917179
Provider Name (Legal Business Name): INTERVENTIONAL PAIN SOLUTIONS, PA.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 WEST ROYAL LANE #230
IRVING TX
75039
US

IV. Provider business mailing address

825 WEST ROYAL LANE #230
IRVING TX
75039
US

V. Phone/Fax

Practice location:
  • Phone: 972-956-5541
  • Fax: 972-956-5504
Mailing address:
  • Phone: 972-956-5541
  • Fax: 972-956-5504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberM6482
License Number StateTX

VIII. Authorized Official

Name: ASHLEY NICHOLE MAWBY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 972-956-5541