=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396119178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL TEXAS PAIN CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2015
-----------------------------------------------------
Last Update Date | 07/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3201 S AUSTIN AVE STE 265
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78626-7641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-876-7246
-----------------------------------------------------
Fax | 855-277-5070
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 208357
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75320-8357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-485-7208
-----------------------------------------------------
Fax | 844-364-8678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/AUTHORIZED OFFICER
-----------------------------------------------------
Name | DANIEL FREDERICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-485-7208
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | J7566
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------