MEDICARE: VALOR INTERVENTIONAL PAIN, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician
2	207LP2900X	Pain Medicine (Anesthesiology) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1528369592	OTHER	TX	NPI INDIVIDUAL

General Provider Information

NPI Number	:	1104440411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VALOR INTERVENTIONAL PAIN, LLC

Provider Business Mailing Address
First Line	:	806 OLD CLEBURNE RD
Second Line	:
City	:	GRANBURY
State	:	TX
Zip	:	76048-1422
Country	:	US
Telephone Number	:	682-936-2544
Fax Number	:

Provider Business Practice Location Address
First Line	:	6620 BRYANT IRVIN RD STE 100
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4224
Country	:	US
Telephone Number	:	682-936-2544
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRADLEY J KENESON II
Credential	:	DO
Telephone Number	:	682-936-2544

Provider Enumeration Date	:	06/02/2020
Last Update Date	:	10/22/2020

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Directions to “VALOR INTERVENTIONAL PAIN, LLC ” Practice Location

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