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General NPI Number Information
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NPI Number | 1942769476
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Entity Type | Organization
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Legal Business Name | WAY OUT WEST SPINE AND MOBILITY PLLC
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Dates
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Enumeration Date | 03/14/2019
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Last Update Date | 07/26/2022
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Provider Practice Location Address
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Address Line | 120 SAINT LOUIS AVE STE 100
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City | FORT WORTH
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State | TX
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Zip | 76104-1256
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Country | US
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Telephone | 682-285-1044
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Fax | 855-361-0894
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Provider Business Mailing Address
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Address Line | 120 SAINT LOUIS AVE STE 100
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City | FORT WORTH
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State | TX
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Zip | 76104-1256
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Country | US
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Telephone | 682-285-1044
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Fax | 855-361-0894
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Authorized Official
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Title or Position | LEAD PHYSICIAN
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Name | MIKE MARTINEZ II
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Credential | DO
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Telephone | 682-285-1044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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