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NPI Code Detail

MEDICARE: PRESIDIO PAIN CENTER, LLC

MEDICARE: PRESIDIO 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
1261QP3300XPain Clinic/Center

General Provider Information

NPI Number : 1790089720
Entity Type Code : Organization
Provider Name (Legal Business Name) : PRESIDIO PAIN CENTER, LLC
Provider Business Mailing Address
First Line : PO BOX 702620
Second Line :
City : TULSA
State : OK
Zip : 74170-2620
Country : US
Telephone Number : 972-234-4740
Fax Number : 972-231-7095
Provider Business Practice Location Address
First Line : 1201 SUMMIT AVE
Second Line : SUITE 400
City : FORT WORTH
State : TX
Zip : 76102-4413
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 : 01/05/2011
Last Update Date : 01/05/2011

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Directions to “PRESIDIO PAIN CENTER, LLC ” Practice Location

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