MEDICARE: BURLESON INTERVENTIONAL PAIN CENTER, 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	261QP3300X	Pain Clinic/Center
2	367500000X	Certified Registered Nurse Anesthetist

General Provider Information

NPI Number	:	1356627988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURLESON INTERVENTIONAL PAIN CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 674147
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267-4147
Country	:	US
Telephone Number	:	972-234-4740
Fax Number	:	972-231-7095

Provider Business Practice Location Address
First Line	:	1805 OWEN CT
Second Line	:	SUITE 119
City	:	MANSFIELD
State	:	TX
Zip	:	76063-4232
Country	:	US
Telephone Number	:	972-234-4740
Fax Number	:	972-231-7095

Authorized Official
Title or Position	:	MANAGER
Name	:	TED GROSBECK
Credential	:
Telephone Number	:	469-362-6909

Provider Enumeration Date	:	10/27/2011
Last Update Date	:	06/06/2016

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