=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528795150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE HOUSTON INTERVENTIONAL PAIN PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2022
-----------------------------------------------------
Last Update Date | 08/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7040 FM 1960 RD E
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77346-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-713-5556
-----------------------------------------------------
Fax | 409-554-0921
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7040 FM 1960 RD E
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77346-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-713-5556
-----------------------------------------------------
Fax | 409-554-0921
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL / MD
-----------------------------------------------------
Name | CRAIG A CHARLESTON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 281-713-5556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------