Provider Demographics
NPI:1013008895
Name:FREEDOM PAIN CARE LLC
Entity Type:Organization
Organization Name:FREEDOM PAIN CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLLIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:817-294-7444
Mailing Address - Street 1:7451 CHAPEL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-7090
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:
Practice Address - Street 1:918 N DAVIS DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-3226
Practice Address - Country:US
Practice Address - Phone:817-860-9933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228850363L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C18VOtherBLUE CROSS BLUE SHIELD
TXB136149Medicare PIN
TX00C18VOtherBLUE CROSS BLUE SHIELD
TX00W106Medicare PIN